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.
A resident with severe dementia and significant behavioral disturbances, including wandering, disrobing, inappropriate urination/defecation, and sexually inappropriate and aggressive behaviors toward others, was involved in a serious incident where he exposed himself, assaulted an LPN, and entered a female resident’s room naked, causing her to fall while trying to escape. Both residents were sent to the ER, and the administrator later stated that an emergency discharge was issued due to the resident’s behaviors endangering others. However, surveyors found no documentation in the electronic health record of the immediate discharge, no record that the resident’s spouse was informed of the discharge and its reasons, and no scanned discharge notice. A separate paper folder contained a discharge notice inaccurately listing the discharge destination as the family home and notes about notifying the receiving facility and spouse, but the administrator confirmed this information was never entered into the electronic record, contrary to the facility’s discharge/transfer policy.
A resident with multiple chronic conditions and moderate cognitive impairment was discharged home without the facility involving her POA in the discharge planning process, despite documentation that the POA had previously provided input favoring long-term placement and a care plan intervention for social services to meet with both resident and family to determine the discharge plan. The resident met with a PA, signed a discharge packet with medication and home health orders, and was picked up by family on the day of discharge, but there was no documented consultation or prior notification to the POA. The DON acknowledged that the family was not included in the discharge discussion, which conflicted with the facility’s discharge planning policy requiring collaborative planning and documentation of resident and representative notification.
A resident with multiple chronic conditions, who was assessed as cognitively intact, was discharged without any documentation in the medical record of their discharge disposition, recapitulation of stay, or discharge arrangements. The record lacked a discharge summary, nursing discharge note, and post-discharge plan of care. The DON confirmed these omissions, which were inconsistent with the facility’s own policy requiring nursing to obtain discharge orders, prepare a discharge summary and post-discharge plan, and complete a discharge note prior to discharge.
Unsafe discharge without required notice: A resident with epilepsy, TBI, severe cognitive impairment, and ongoing behavioral symptoms was sent with her husband to an ER after staff-directed aggression escalated. The hospital did not admit her, the facility then refused readmission, and the resident was ultimately taken home. The record showed no discharge notice or appeal rights were provided before the discharge, and the facility’s own policy allowed discharge only under limited circumstances.
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