A resident with a recent hip fracture, bipolar disorder, and anxiety disorder was allowed out on therapeutic pass but was not permitted to return when she came back after the pass. Staff completed discharge paperwork, packed her belongings, and treated her as discharged even though the facility’s policy stated residents must be allowed to return after therapeutic leave regardless of payment source. The resident said she had nowhere to go, and the record showed conflicting staff accounts about whether she had left AMA or could return.
A resident with severe cognitive impairment, multiple medical diagnoses, and escalating aggressive behaviors was sent out for psychiatric placement after assaultive incidents and continuous 1:1 supervision. Facility notes showed repeated agitation, cursing, punching walls, and striking another resident with a door. After the resident was denied admission by the behavioral facility, LTC staff stated he would not be readmitted, despite acknowledging that return after discharge is a resident right.
A resident with DM, morbid obesity, CVA, dysphagia, and significant ADL dependence was discharged for nonpayment even after the Ombudsman notified the facility that an appeal had been filed. The facility’s policy stated the resident should have remained in the facility while the appeal was pending, but staff and admin still proceeded with the discharge to a group home the resident did not want.
A resident with dementia, schizophrenia, cerebral palsy, and severe cognitive impairment was discharged after an inappropriate touching incident involving another resident. The chart lacked physician documentation stating the basis for the transfer/discharge or that remaining in the facility would endanger anyone’s health or safety. Interviews with the family member, SW, DON, and ADM confirmed the discharge was driven by the behavior event and that no physician note supporting the discharge could be found.
Improper Discharge Notice Issued: A resident with intact cognition, PTSD, depressive disorders, and schizophrenia received a 30-day discharge letter stating nonpayment as the reason for discharge, even though staff later acknowledged that was not the actual basis. The resident reported a verbal altercation with an LPN, police involvement, and that the discharge letter made him feel sad and frightened. The DON, business manager, SW, and ombudsman gave differing accounts of the notice and follow-up, and the SW confirmed there was no formal trauma assessment process.
A resident with severe cognitive impairment, stroke, and DM2 was issued an involuntary discharge notice for non-payment, appealed it, and won at fair hearing when the notice was reversed. While the appeal was pending, she was hospitalized and later transferred to an LTAC, but when the LTAC tried to send her back, the facility told the family she could return only if payment was made toward the balance and the Ombudsman was told she would not be returning.
A resident with hepatic encephalopathy, cirrhosis, and moderate cognitive impairment was discharged despite repeated concerns about confusion, exit-seeking, and living alone. Staff and the family member described him as needing supervision, while the external doctor stated he should not live unsupervised. The SW said Home Health was arranged, but the referral was not actually received until later, and the resident was sent home by Uber without confirmed post-discharge support or clear medication management.
A resident with epilepsy, cerebral palsy, and severe cognitive impairment was discharged to a group home without an agreed discharge date being confirmed with the receiving facility, without a completed nurse-to-nurse report, and without PASRR services being communicated. The LVN said she tried to call for report but got no answer, while the receiving facility said it was not told the resident was PASRR positive and was not prepared for the transfer when he arrived.
A resident with stroke, hip fracture, ESRD on dialysis, DM2, CHF, AFib, HTN, and repeated falls was discharged after limited and conflicting discharge planning. The resident and FM stated they were not told in advance that he would be sent to a group home/boarding house, and the placement lacked nursing staff, skilled services, DME, dialysis transportation, and communication support for a Spanish-speaking resident. The DON stated she did not verify the placement, and the resident was removed the same day after becoming upset and frightened.
Failure to Provide Required Discharge Notice: A resident with COPD, acute respiratory failure, and syncope was discharged after the facility gave only a 3-day notice based on an insurance notice, rather than the required 30-day discharge notice. Records showed discharge paperwork dated with a discharge date only days later, the care plan did not show discharge planning, and staff interviews confirmed the FM was notified according to the insurance timeframe instead of facility policy.
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