A resident with a G-tube, Foley catheter, oxygen needs, malnutrition, and a stage 2 sacral pressure ulcer was discharged without a safe, orderly plan in place. The record showed missing discharge documentation, no confirmed home health or DME arrangements, and no documented tube-feeding, wound-care, or Foley-supply education. The resident reported receiving only a few bottles of tube feeding, having no pump or supplies, going days without oxygen, and having no wound-care supplies or home health aide support after discharge.
A resident with dementia, anxiety, depression, and a BKA was sent to the hospital after yelling at staff and calling 911, but the facility used an AMA form for the transfer even though staff later said AMA paperwork was not meant for hospital transfers. The resident had a court-appointed guardian, the AMA and bed hold paperwork were incomplete, and the facility then refused to take the resident back, leaving the guardian to find another placement.
A resident with CHF, DM2, and altered mental status was sent to the ED for evaluation and later returned with a UTI diagnosis, but facility staff refused to let her back in because of an unpaid balance and disputed insurance coverage. The RN said she was told not to take the resident back, the NHA confirmed the resident was denied entry, and the resident was sent back to the ED in the middle of the night with no place to go, no ID, no money, and significant distress.
Failure to readmit a resident after hospitalization: A resident with autism, ADHD, OCD, anxiety, seizures, gastroparesis, and POTS became distressed after being told she would have a roommate and called 911 stating she did not feel safe and had suicidal thoughts. She was sent to the hospital, where records later showed she was medically stable and a safe discharge plan back to the facility was coordinated, but facility leadership refused readmission because of the SI she had expressed. The medical record also lacked documentation of why her needs could no longer be met or the basis for discharge.
A resident with type 2 DM, a cardiac pacemaker, and dependence on staff for most ADLs was care planned to return home with HHC supports, including services from a specified home health agency starting shortly after discharge. However, the facility did not ensure that the home health referral was actually made and confirmed before discharge. The care coordinator stated they had not sent the referral and believed a former social worker had done so, and later learned from the agency that no referral had initially been received. The home health agency reported that the referral was not received until several days after discharge, at which point services were initiated, resulting in a delay between discharge and the start of home health care.
A resident with dementia, multiple comorbidities, and an ileostomy was determined by two MDs to lack capacity for medical decision-making and was left without an active POA after the designated family POA resigned in writing. Despite this, the facility had the resident sign a Medicare non-coverage notice, did not complete the care-planned home safety visit, and discharged the resident home based on the resident’s request and an assumption that the former POA would still provide support. Social services documented planned home health (PT, OT, nursing, HHA) and a PCP visit, but the listed home health agency later reported the resident was never evaluated or enrolled, and a family member found the resident at home alone in poor condition. The NHA and SSD acknowledged they did not seek emergency guardianship and could not confirm the resident’s safety or that appropriate support services and a patient representative were in place at discharge, and they did not inform a sister facility that the resident lacked a guardian or POA when asked for information.
A resident with quadriplegia, depression, and schizoaffective disorder was sent to a hospital for psychiatric evaluation after exhibiting behavioral changes. Hospital records show the resident was cleared to return and repeatedly stated they only wanted to go back to their prior facility, but the DON informed the hospital that the physician wanted the resident transferred to a sister facility and that the home facility would not accept the resident back. The resident reported their belongings had already been moved to the sister facility, and hospital notes documented the resident’s refusal to go there. Facility progress notes did not document any agreement by the resident to transfer, any police arrests, or changes in leave-of-absence status, despite the facility’s policy requiring notice, preparation, and information about appeal rights for transfers and discharges.
A cognitively intact resident with chronic hypoxic respiratory failure and morbid obesity was transferred to a hospital with unclear and poorly documented reasons in the EMR, which only noted constipation and an O2 saturation in the low 80s. The ADON acknowledged that the discharge was not properly documented and that the reason for sending the resident out was unclear. After the resident became medically stable in an out-of-state hospital, the resident, hospital CM, and Ombudsman reported that the resident wished to return and had been educated on the risks of using BiPAP instead of AVAP, but the NHA repeatedly delayed or refused readmission, citing an inability to manage AVAP and daily ABGs despite a sister facility’s experience with AVAP. A hospital-arranged transport returned the resident to the facility after a long trip, but staff, reportedly under the NHA’s direction, did not open the door or accept the resident, forcing a return trip to the hospital. These actions conflicted with the facility’s own transfer/discharge policy requiring clear physician documentation, appropriate criteria for transfer, and proper notice and process.
A resident with hemiplegia and dependence for transfers was discharged home without effective discharge planning or documentation. The care plan called for coordinated discharge orders, home health and therapy referrals, and DME, but social services did not clearly assist with the insurance appeal process, did not document a comprehensive discharge plan, and did not arrange post‑discharge services. The family member reported receiving short‑notice of discharge, no caregiver education, no referrals for home health or outpatient therapy, and no help obtaining needed DME such as a wheelchair and hospital bed. Nursing staff were unaware of the exact timing of discharge and the ambulance left without the printed discharge paperwork. Therapy staff were not informed in time to complete a discharge assessment and stated the resident remained dependent with transfers and unsafe to stand. The discharge packet later found in a shred box was incomplete, lacking transportation details, instructions review, signatures, and key contact information, demonstrating that the resident was discharged without a safe, orderly, and well‑documented transition plan.
A resident with dementia, severe cognitive impairment, and multiple chronic conditions left AMA after becoming upset and refusing care. The resident said he had used the call light many times and waited hours for a toothbrush, while family said they would not pick him up. The record showed no APS or welfare check referral, no discharge summary, no home care referral, and no documentation of when, how, or with whom the resident left.
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