A resident with cognitive impairment and prior burn injuries was discharged to homelessness/vehicle living without documented completion of the stated home health referral, despite notes that the discharge plan was unsafe and that the resident needed PT/OT/ST. The resident later sustained serious fractures after being found on the ground outside the vehicle. In a later discharge episode, the resident was documented as confused, a fall risk, and needing assistance with ADLs and neck brace/med management, yet left before neurosurgical clearance and there was no documented AMA signature or completed home health referral.
Unsafe Discharge of Cognitively Impaired Resident: A resident with dementia, severe cognitive impairment, limited mobility, and elopement risk was discharged alone by taxi to a bus station with a prepaid ticket for travel home. Despite staff concerns raised before discharge, no staff accompanied the resident, and the resident missed the bus and was found confused by a bus station attendant before being returned to the facility.
A resident with MS who required assistance with transfers, dressing, and bed mobility was found to have marijuana in the room, which the resident said a friend had brought and removed after staff intervention. The next day, after staff reported smelling marijuana and described the resident as yelling, cursing, and kicking furniture, the social services director, medical records director, and an LPN informed the resident that care would be discontinued and that the resident would be discharged home the same day for violating the facility’s no-marijuana policy. Multiple staff entered the room, the resident refused to leave and became more upset, and law enforcement was contacted, while a notice of involuntary transfer and a discharge summary citing non-compliance with policy were completed without arranging home health services. Staff interviews later gave conflicting accounts about whether the resident had actually smoked marijuana, and the resident reported feeling overwhelmed, attacked, and without alternatives, illustrating that the discharge process did not ensure a safe and orderly transition consistent with the resident’s needs.
A resident with chronic pain and a left below-knee amputation, who required supervision or touching assistance with ADLs, was discharged after returning from an outing shortly after midnight. Although discharge instructions noted the need for assistance and assistive devices, there was no documentation of referrals for medical equipment or home health services. Facility staff documented that the resident was discharged because they were out past midnight and believed Medicare would not cover the stay, did not issue a NOMNC, and recorded the discharge as voluntary despite the resident later reporting they had been “kicked out” and were sleeping on a friend’s couch with difficulty getting around. Staff interviews revealed no financial issues and indicated the resident had originally been scheduled for discharge at a later date.
Failure to Send Discharge Medications With Resident: A resident with seizures and anxiety was discharged to an ALF without remaining doses of lacosamide and clonazepam, even though the chart noted medications were provided. Controlled substance records showed the meds stayed in the facility until later disposal, and staff confirmed the resident should have left with these scheduled medications.
A resident was discharged without a documented discharge plan, as required. Review of the clinical record showed the discharge plan was overdue, and neither the care plan nor care conference notes addressed the resident's discharge preferences. Staff interviews confirmed the discharge plan was not completed and revealed a lack of familiarity with the discharge planning procedure.
Two residents were discharged without adequate coordination or verification of post-discharge support. One was sent home without confirming the availability of a friend to assist or assessing home safety, resulting in exposure to unsafe living conditions. Another was discharged with incomplete instructions, missing a follow-up appointment due to outdated paperwork. Staff did not ensure all necessary information and resources were provided prior to discharge.
A resident with a recent fracture was discharged home without a completed home health referral or necessary caregiver, PT, and OT support services, despite prior care planning and physician recommendations. The resident and family had to arrange for care independently after discharge, and facility leadership acknowledged the lapse.
A resident discharged after a stroke did not have therapy orders signed before leaving the facility, as the physician was unavailable. Although home health services were recommended, the lack of signed orders delayed the start of physical and occupational therapy until the resident saw their primary care physician after discharge.
A resident with congestive heart failure and delusional disorders was discharged to a home lacking basic utilities and infested with rats, despite prior IDT concerns and without the primary physician's involvement in discharge planning. Documentation did not show that the IDT met to ensure a safe discharge, and facility leadership could not provide further information.
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