A resident with hemiplegia, aphasia, unsteadiness, ADL deficits, and fall risk had a care plan indicating a desire to remain for LTC, but the facility issued a NOMNC ending Medicare coverage without completing required provider sections and without updating the care plan to reflect an active discharge plan. The DCT documented functional barriers such as stairs and bathing, sent referrals to other facilities, and acknowledged not asking the resident about specific transfer preferences or consistently documenting discharge-planning discussions. The Administrator and DCT told the resident they could not stay, actively sought alternative placement, and discussed possible return to a motel, while no formal discharge notice was issued and the existing care plan still showed an initial plan for LTC.
Staff failed to follow the facility’s emergency transfer/discharge policy when they discharged a resident to a local hospital for safety reasons and refused to allow the resident to return. The resident had been in the facility less than 24 hours, refused care, and made threats that scared staff, leading the administrator to authorize an immediate emergency discharge. Documentation included a progress note and an Immediate Discharge Notice listing the hospital as the discharge location for resident and staff safety, despite the administrator acknowledging that a hospital is not an appropriate discharge location. These actions resulted in the resident being discharged to a hospital without an appropriate emergency discharge notice that ensured the transfer met the resident’s needs/preferences and prepared the resident for a safe transfer/discharge.
A cognitively intact resident with paraplegia, cognitive communication deficit, and major depressive disorder received a 30‑day involuntary discharge notice for non‑payment that contained an incorrect discharge date and lacked complete receiving‑facility information. The facility proceeded with discharge planning despite a care plan entry indicating the resident opted to stay and despite the resident’s expressed desire to remain where they had friends. After the resident’s family notified the facility and the Ombudsman by email that they were appealing the discharge, the facility did not review the appeal email until after the resident had been transported by facility van to another facility and did not allow the resident to return while the appeal was pending, contrary to policy and appeal protections.
Facility staff discharged a resident to a hospital and then refused to allow the resident to return, without having an emergency discharge policy in place. Staff documented an immediate discharge notice stating the facility could no longer meet the resident’s needs and listed the hospital as the discharge destination. The administrator stated the resident would not be accepted back due to safety concerns for other residents and acknowledged that the hospital was not an acceptable discharge location. A care plan coordinator notified the hospital social worker by email that the facility would not readmit the resident, resulting in an inappropriate emergency discharge notice and failure to ensure the transfer/discharge met the resident’s needs and preferences.
A resident with CHF, DM, morbid obesity, and HTN was sent to the hospital after shortness of breath and syncope, but the facility did not document a discharge order, bed hold, transfer notice, or written discharge notice when the resident was not allowed to return. The hospital social worker reported the facility said it would not accept the resident back, while the DON and Administrator stated the resident’s weight and the facility’s lack of equipment/resources prevented readmission.
Surveyors found that the facility failed to ensure safe, coordinated discharge planning for two residents, contrary to its own policy requiring IDT involvement, physician orders, referrals, and discharge summaries. One resident with multiple conditions, including diabetes and visual impairment, reported being told by the SW that it was not her job to find a new placement or assist with an appeal, and therapy staff stated the resident was non-ambulatory, required assistance with ADLs, and was unsafe to manage numerous stairs at home, yet the resident was still discharged after arranging personal transportation. Another cognitively intact resident with several chronic diagnoses was discharged home with medications but had no physician discharge order, no documented discharge planning, referrals, or discharge summary in the record, despite the DON’s stated expectation that such planning and documentation occur.
A resident with multiple cardiac, cognitive, and functional diagnoses was moved from the facility to another SNF within the same company without a physician discharge order, required discharge notice, or completed discharge documentation in the medical record. The facility’s policy required advance written notice of transfer/discharge, including reasons, effective date, destination details, appeal rights, and Ombudsman information, to be provided to the resident and their representative, and for discharge planning and documentation to be maintained. Instead, staff communicated discharge plans with a family member who was not the resident’s DPOA, while the designated DPOA reported not being notified of the discharge, not receiving any discharge paperwork or notice, and not being contacted by or signing admission paperwork for the receiving facility. The DON stated that staff were expected to notify and obtain agreement from the DPOA or provide a 30‑day notice, and the Administrator acknowledged that no discharge notice was completed because staff believed the move to another SNF was a transfer rather than a discharge.
A resident with schizophrenia, bipolar disorder, depression, anxiety, obesity, and a history of significant behavioral and psychiatric issues was admitted after a preadmission review deemed the individual appropriate for care, with a care plan noting anger, threats, suicidal thoughts, and need for 2-person assistance. Nursing notes described escalating anxiety, frequent requests for hospice, excessive call light use, attempts to pull staff into bed, and an episode involving chest pain, suicidal/homicidal statements, and object throwing that led to EMS transport to a hospital. After the hospital treated the resident and sought to return the individual, facility social services informed the hospital and the guardian that the resident would not be accepted back, and the Administrator cited behavioral concerns and need for psychiatry as reasons; however, the facility failed to document in the medical record any reason why the resident’s needs could not be met at the time of attempted return, contrary to its own transfer/discharge policy.
A resident with a history of aggressive behaviors was sent to a hospital for psychiatric evaluation after multiple assaults on staff. The facility issued an immediate discharge notice while the resident was hospitalized, but failed to specify an appropriate discharge location as required, instead listing the psychiatric hospital. The discharge notice was not amended to correct this, resulting in a deficiency.
A resident with diabetes and cognitive impairment was sent to a hospital following two altercations and was subsequently issued an Immediate Notice of Involuntary Discharge. Facility staff, including the administrator and DON, determined the facility could not meet the resident's needs and refused readmission after hospital treatment. The resident was not updated on their status and expressed distress about not being allowed to return, while the social services designee sought alternative placements and notified the Ombudsman. The facility's policy lacked guidance on immediate involuntary discharges, and staff acknowledged noncompliance with regulations regarding reevaluation after treatment.
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