Facility staff refused to accept a resident back after a hospital psych eval, despite hospital records showing the resident was alert, oriented, cooperative, and did not require psych hospitalization. The resident had a hx of DM2, Afib, and CVA with L-sided hemiparesis, and had exhibited behavioral issues during discharge planning. When the ambulance returned the resident to the facility, staff denied entry and the resident was sent back to the hospital.
A resident with schizophrenia, bilateral BKA, and a history of substance abuse was discharged without documented confirmation of a safe receiving placement, without prior notification to the county DSS, and without records showing transport details, discharge instructions, medication reconciliation, a physician discharge order, or a post-discharge summary. Social work had pursued multiple housing options after a prior supportive living facility refused readmission and an ALF referral was declined, but the chart still lacked documentation of where the resident actually went and what discharge services were arranged.
A resident with COPD, pulmonary HTN, CHF, CKD, and hypoxic respiratory failure was discharged home after completing rehab, with documentation stating their health had improved sufficiently to no longer need facility services. In the days before discharge, a provider ordered PRN guaifenesin for cough and a COVID/flu respiratory panel, and the resident received cough medication twice, with one dose documented as ineffective. The swab was collected, but there was no documentation of the rationale for the orders, no evidence that test results were obtained or reviewed, and no provider evaluation of the resident’s clinical status after these orders and before discharge. Staff reported the resident had cough and congestion and that family requested testing, while leadership stated the resident had no respiratory symptoms at discharge and that results would not have been available due to outside lab processing. The complainant reported the resident was very ill at discharge and that attempts to delay discharge were unsuccessful. The resident was hospitalized shortly after discharge with shortness of breath, weakness, a one-week history of respiratory symptoms, and was found to have influenza and acute on chronic heart failure exacerbation, leading surveyors to cite a failure to ensure an appropriate and safe discharge.
A resident with vascular dementia, behavioral disturbances, and dependence for transfers and toileting was sent to the hospital for suspected GI bleeding, with documentation indicating an unplanned hospital transfer and anticipated return. An IDT meeting held earlier did not document any discharge planning, and the resident’s care plan lacked a planned discharge. While the resident remained hospitalized, the facility issued a same-day discharge notice citing inability to meet needs and endangerment to others, based on interference from the resident’s guardians rather than documented resident behavior, and later did not accept the resident back after medical clearance. The medical record contained no IDT discharge plan and no subsequent nursing or social work notes, demonstrating a lack of documented discharge planning and coordination.
A resident with autism, severe ID, and limited mobility was sent from the facility to a hospital for an MRI without a clear discharge plan, physician clearance, or written notice to the guardian. The record lacked a discharge summary and social work documentation, the transfer paperwork listed behavioral symptoms rather than the test, and the group home had not arranged for the resident’s return. The resident arrived at the hospital outpatient area without an order, was redirected to the ER, and was left without a planned return to the facility or group home.
A resident with Parkinson’s disease, dementia, and known behavioral issues was sent to a hospital after being found in another resident’s room and had a care plan including 1:1 interventions and 15‑minute checks. After the transfer, the MD and SW informed the family that the facility could no longer meet the resident’s needs and would discharge the resident, directing the family to the hospital SW for alternative placement and discussing packing belongings and benefit redirection. The DON stated the resident required a locked unit due to exit‑seeking, that 15‑minute checks had failed, and that the facility chose not to readmit the resident while its investigation was ongoing. The family reported they were told the resident would not be accepted back, were not met with regarding discharge, and were not given alternative placement options, and the resident was instead sent to another hospital unit used to hold behaviorally complex residents while awaiting nursing home placement.
A resident with diabetes and diabetic wounds was discharged without proper education, supplies, or medication reconciliation, and without confirmation of safe housing or supportive services. The resident, lacking identification and a primary care provider, was sent to the Department of Social Services without prior coordination, resulting in denial of emergency housing and subsequent hospitalization for severe hyperglycemia.
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.
The facility failed to maintain an effective discharge planning process for two residents. One resident with cardiac arrest, a coagulation defect, and AFib was progressing with PT and wanted to return home, but there was no documented ongoing re-evaluation of discharge goals while the resident remained in the facility for daily heel wound care. Another resident with a femur fracture and orthopedic aftercare wanted to leave AMA and return to an apartment, but the record showed no active discharge plan, no documented ongoing reassessment of discharge goals, and no completed discharge planning documentation despite the resident’s impaired cognition, dependence for mobility, and stated need for home services.
A resident with renal abscesses, vertebral osteomyelitis, and discitis wanted to return home, but discharge planning was not kept current or tied to the resident’s stated goal. Records showed the resident needed max assist or dependence for most ADLs, later required 2-person assist and could not ambulate, and had ongoing needs including nephrostomy care and IV antibiotics. The resident asked about the discharge plan and said no one was helping with therapy or discharge toward home, while staff acknowledged they did not follow up after the last care conference and waited for quarterly meetings to discuss discharge planning.
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