Failure to Develop a Person-Centered Discharge Plan: A resident with right-sided hemiparesis/hemiplegia, aphasia, contracture, unsteadiness, ADL dependence, and a stated wish to remain in LTC was given a 30-day discharge notice and told the discharge location would be a homeless shelter unless another plan was made. Records showed alternate placement was not discussed in the care management note, while social services and the Administrator met with the resident to issue the notice and discuss appeal rights. The NP stated the resident still needed medication management and protective oversight, was not included in the discharge planning meeting, and did not approve of discharge to a homeless shelter.
A resident with hemiplegia/hemiparesis, anxiety, and PTSD was issued a 30-day discharge notice, but the facility did not send a copy to the Ombudsman at the time it was issued. The resident said nobody in Kansas City knew about the notice and could not appeal, while the Ombudsman confirmed the office had not received the letter; the Social Worker said he/she believed notification was not required until the resident was officially discharged.
A resident was emergency discharged after making statements of self-harm and threatening staff, but the discharge notice did not include a location. The administrator said the resident was sent to the hospital for safety concerns, the facility refused the resident’s return after the hospital stay, staff did not try to find a new facility, and the Ombudsman was not contacted.
Failure to Readmit Resident After Dismissed Immediate Discharge: A resident with adjustment disorder, depression, anxiety, substance use history, chronic wounds, and a colostomy displayed repeated sexually inappropriate, verbally abusive, and threatening behaviors, leading the facility to issue an immediate discharge notice and send the resident to the hospital for psych eval. The DHSS Appeals Unit later dismissed the discharge because the notice was defective and missing required appeal information, but the facility refused to allow the resident to return despite the dismissal.
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.
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