A resident with CHF, DM2, COPD, PVD, HTN, and PTSD received discharge notices after making threats toward the Administrator and was sent for psych eval. After the hospital cleared him and documented that he was calm, cooperative, and denied SI/HI, the facility still refused readmission, told hospital staff he could not return, and left him without a safe discharge location while the Ombudsman noted the discharge paperwork was improper.
A resident with ESRD, dementia, and mobility limitations was discharged home with dialysis and HHS arranged, but the discharge planning notes did not address 24-hour care, med management, transportation, or whether family could assist with transfers and stairs. Therapy documented the resident needed significant assistance and PT recommended 24-hour care, yet the resident was discharged and soon missed dialysis, was found wandering outside his home, and told hospital staff he felt unsafe, could not cook, and had trouble walking.
A resident with bipolar disorder, TBI, and schizoaffective disorder had repeated behavioral incidents with another resident, including an assault that led to police involvement and arrest. The facility issued an emergency discharge notice to jail, then refused to take the resident back after court release, leaving the resident hospitalized while placement was sought. Interviews confirmed the resident had no current medical need for hospital care, and the record showed no documented assistance from the facility with alternate discharge planning after readmission was denied.
Failure to Provide Required 30-Day Discharge Notice: A resident with dementia and repeated elopement behavior was transferred to a sister facility with a secure memory care unit after cutting off a wander guard and leaving the building area. The facility did not provide a 30-day discharge notice, and the discharge paperwork stated a shorter notice was used because the resident’s welfare and needs could not be met in the facility. The resident’s family agreed to the transfer, and the RSC confirmed the transfer was arranged without the standard notice period.
A facility failed to document the reason for resident transfers when it temporarily closed and moved 16 residents to a sister facility. Records for three residents showed no transfer reason in the chart, even though one resident’s daughter/POA and two legal guardians were contacted and agreed to the move. One guardian said the first notice received was an email about renovations and relocation, and the Administrator confirmed phone calls were made but not documented.
A resident with paraplegia, cognitive impairment, and dependence for most ADLs became physically aggressive, assaulted an LPN, and was sent to the ER after police were called. When the resident returned, staff refused readmission because they felt unsafe, there was no evidence of discharge paperwork or notice, and the DON confirmed psych services were not contacted for review.
A resident with diabetes, chronic wounds, functional quadriplegia, and multiple mental health and substance use diagnoses was discharged after behavioral concerns and a fire alarm incident, but left with only his belongings and no discharge instructions, wound care instructions, or meds. The transfer notice listed a homeless shelter without an address, and the resident later reported living on the streets until his motorized wheelchair battery died and he was found in a grocery store parking lot before hospital evaluation.
A resident discharged home with multiple chronic conditions, including CVA, HTN, atrial fibrillation, and kidney cancer, did not have an adequate medication supply after leaving the facility. Although the discharge summary listed follow-up care and the resident was sent with medications and education, the facility did not call the prescriptions into the pharmacy at discharge; the NP did so several days later, and only one day of meds had been provided initially.
A resident with HIV, anemia, psoriasis, anxiety, depression, homelessness, and financial hardship was discharged without a safe and appropriate discharge plan. The record showed limited housing support, repeated LOAs, invalid contact information, no LOA order in the chart, and unsuccessful attempts by staff to locate or reach him. The resident also expressed concern about where he would live after discharge and declined offered community contacts.
A resident with Parkinson’s disease, CAD, HTN, and impaired cognition had repeated elopement attempts, wandering, hallucinations, agitation, and verbal aggression, including trying to leave with visitors and throwing a cane at an LPN. The family requested transfer to a secured memory care unit, but only limited referral documentation was available and there was a prolonged gap in social services notes before the resident was later accepted to a secured unit.
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