A resident with schizoaffective disorder, dementia with behavioral disturbance, and PTSD had a history of verbal and physical aggression, exit-seeking, and medication refusal, culminating in an incident where the resident struck a nurse and was sent to an acute psychiatric hospital. Facility documentation showed no 30‑day transfer/discharge notice to the resident’s representative, no documentation of appeal rights or bed-hold policy, and a discharge MDS that characterized the hospitalization as an unplanned discharge with return anticipated. After transfer, the psychiatric hospital Social Worker repeatedly attempted to coordinate the resident’s return, but the DON was often unavailable, the receptionist stated the resident was not allowed back, and facility staff gave inconsistent, undocumented explanations that the resident would not be re-admitted or had been discharged to another SNF, despite the hospital and the representative reporting no such acceptance. The facility’s actions and omissions conflicted with its own transfer/discharge policy requiring 30‑day notice for non-emergency discharges, continuity of care planning, and provision of bed-hold information.
Incomplete Transfer and Discharge Documentation: A resident with DM and moderate cognitive impairment was sent to the hospital without progress notes, discharge assessments, respiratory assessments, or a completed transfer/discharge and bed-hold form in the chart. The CNM and Regional Support confirmed the resident had no assessments or documentation leading up to the emergent transfer, and the facility policy required transfer/discharge documentation to be included in the medical record.
Missing transfer/discharge documentation for two residents. One resident was discharged to another LTC facility after a stroke-related hospital stay, but the facility could not provide the transfer/discharge paperwork that should have accompanied the resident. Another cognitively intact resident with cancer and heart failure was sent to the ER at a family member’s request, but the record lacked documentation that a transfer/discharge form was provided. An LPN described expected discharge paperwork, and the DON stated staff often failed to make copies of transfer/discharge records.
A resident with HTN and moderate cognitive impairment was discharged without a complete discharge record, including discharge assessments, a medication list, or referral information for a cardiology follow-up that had been anticipated due to uncontrolled BP and epigastric pain. The discharge form only listed the diet and a PCP follow-up, while the DON, RN, and SSD confirmed that medication and specialty follow-up information were not provided.
A resident with severe cognitive impairment, multiple medical conditions, and significant care needs was discharged home alone without verified support or caregiver involvement. The facility did not assess the resident's ability to manage her prescribed diet, medications, or activities of daily living, nor did it provide discharge education to a responsible caregiver. The facility relied on unverified statements about a support network and did not assist with Medicaid applications or power of attorney, resulting in the resident being discharged to an unsafe environment.
Incomplete transfer documentation for two residents. One resident with intellectual disabilities, aphasia, and DM had signs of acute change and was sent to the ED, but the record lacked documentation of preparation for transfer, an assessment at the time of transfer, and physician notification related to the transfer. Another resident with chronic respiratory failure, DM, major depressive disorder, and multiple pressure ulcers had hypotension, altered mental status, poor intake, and low urine output before being sent to the ED, but the record lacked a current transfer assessment and documentation that the resident and/or representative was oriented and prepared for discharge.
A resident was not adequately prepared for a safe transfer or discharge, and the facility did not ensure that the process met the resident's needs and preferences, resulting in a deficiency related to proper transition planning.
A resident was not adequately prepared for a safe transfer or discharge, and the process did not meet the individual's needs or preferences.
A resident with multiple neurological diagnoses was discharged without complete documentation, as required by facility policy. The discharge form lacked a selected reason for transfer, and the physician's order did not provide sufficient detail regarding the discharge. Staff interviews confirmed that required documentation fields were left blank or incomplete.
A resident with multiple chronic conditions and a history of verbal aggression was discharged after a verbal altercation and police involvement, but the facility failed to provide supporting documentation or rationale for the discharge, did not address the resident's needs or preferences, and did not offer the resident the opportunity to return after hospital observation, resulting in a deficiency related to safe and appropriate discharge procedures.
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