A resident receiving IV antibiotic therapy was discharged after facility leadership learned the resident was a Level 3 sex offender under Megan's Law and said they could not have the resident living there for fear of inappropriate behaviors. The DON confirmed the facility accepts residents with IV therapy orders, and the resident's chart contained no documented behaviors to support the discharge decision.
A resident with Type 1 DM and intact cognition was admitted after an insulin pump malfunction and was managed with sliding-scale insulin lispro in the facility. When the pump was repaired, the facility told the resident pumps were not allowed, and the resident left AMA to resume pump use; the record showed no documented discharge goal or individualized discharge plan addressing the resident’s preference, goals, or discharge needs.
A resident attempted suicide, was transferred to the hospital, and the facility told the hospital it would not accept the resident back because it could not meet his needs. The record lacked the required physician documentation explaining why the needs could not be met, the facility's attempts to meet those needs, the services available at the receiving facility, and written discharge notice to the resident, resident representative, and State Ombudsman.
Incomplete discharge instructions and supplies for a resident with pressure ulcers: a cognitively intact resident who was dependent for multiple ADLs and had an unstageable R buttock wound and a new stage 2 L buttock wound was discharged home with his brother, but the discharge paperwork only addressed the R buttock wound. There was no documented evidence that wound care instructions, wound care supplies, or wound meds were given to the resident or his brother at discharge.
A facility failed to readmit a resident after his Medicaid bed-hold expired. The resident had been transferred to the hospital for a higher level of care, and the hospital SW reported he was ready to return, but the facility later said his bariatric bed had been given to another resident and that he was too large to accommodate. The resident was ultimately discharged to an out-of-state facility and was upset about being far from home and unable to retrieve his belongings.
A resident with HF, kidney disease, an irregular heartbeat, and a prior knee replacement requested transfer to two different LTC facilities, but the record showed no updated Social Services documentation of referral status for a long period. The discharge planning care plan only addressed evaluating care needs and potential discharge to the most appropriate level of care, and Social Services confirmed the care plan was not updated timely to include referrals and responses.
A resident with DM and hemiplegia/hemiparesis, who was cognitively intact and served as his own RP, repeatedly requested discharge home and reported he could independently perform insulin injections and BG monitoring before admission. Although social services identified diabetic teaching as a discharge barrier and nursing documented education, the record showed no reassessment of discharge readiness, no physician notification about the resident’s demonstrated self-care abilities, and no updated discharge planning despite the resident’s repeated requests to return home.
A resident with CHF, Alzheimer's disease, AFib, and other chronic conditions was discharged after a brief rehab stay without clear documentation supporting the reason for discharge. The record lacked evidence that therapy goals were met, that the resident or RP requested discharge, that appeal rights were provided, or that the discharge plan was signed; staff later said the discharge was due to aggressive behaviors, but there was no physician documentation or record evidence showing the behaviors endangered others or that attempts were made to manage them.
Failure to implement discharge planning before a resident’s discharge. A resident with rhabdomyolysis, severe frostbite with foot necrosis, and a skin infection was discharged after the physician noted outpatient surgery was delayed and hospital re-evaluation was needed. The record showed medication education and transport by ambulance, but SS, the resident’s representative, and the Administrator all indicated the representative was not informed, the resident’s belongings remained at the facility, and no home care or wound care services had been arranged.
A resident with hyperlipidemia, HTN, dysphagia, and macular degeneration was documented as discharged with her son to an ALF, with scripts and discharge paperwork sent, but the clinical record did not include a physician order for discharge to Assisted Living/Personal care. The care plan called for staff to notify the doctor of discharge plans and help facilitate a safe discharge, and the NHA confirmed the missing discharge documentation.
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