Failure to issue emergency discharge notice: A resident was sent to the hospital for uncontrolled pain and then told the facility would not accept the resident back because the acuity of care was higher than anticipated. The record contained no documentation of an emergency discharge notice, and the DON and Administrator stated the resident’s needs could not be met and no written discharge was issued.
A resident with significant cognitive loss and a history of behavioral problems, including self-harm gestures, aggression toward others, and destructive acts, was hospitalized after escalating violent behaviors. The facility then initiated an emergency discharge and refused to allow the resident to return, but the transfer/discharge form in the record was incomplete and the administrator stated there was no transfer and discharge policy.
Failure to Follow Discharge Procedures After Immediate Discharge: A resident with repeated PCP use, AMS episodes, and multiple hospital transfers was issued an immediate/emergent discharge after violating the facility’s drug and alcohol policy and behavioral contract. After the resident left the facility with DPOA permission and was later sent to the hospital again for suspected intoxication, the hospital social worker said the resident would return despite the facility’s discharge paperwork, and staff documented that the resident was not to be accepted back.
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.
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