Failure to Ensure Safe Discharge of Resident with Mental Illness
Summary
The facility failed to ensure that a resident, who lacked the capacity to understand and make decisions, was not discharged against medical advice (AMA). The resident, who had a history of paranoid schizophrenia and other medical conditions, was discharged without a valid Out On Pass (OOP) or AMA order on the day he wanted to leave. The facility did not assess the resident's ability to understand his medication regimen before providing him with a total of 41 tablets of Haldol at the time of discharge. Additionally, there was no referral made to the shelter before allowing the resident to leave, and the resident's responsible party was not notified prior to the discharge. Consequently, the resident was not accepted by the shelter and is now missing, with his whereabouts currently unknown. These failures placed the resident at high risk for various health complications and possible death. The resident had a fluctuating capacity to make decisions and required assistance with daily activities. Despite this, the facility allowed the resident to leave AMA without proper documentation or assessment. The resident's psychiatrist and the local sheriff were involved in the decision-making process, but the facility staff did not follow the appropriate procedures for a safe discharge. The resident was given a 20-day supply of Haldol without an assessment of his ability to self-administer the medication, and there was no follow-up to ensure he arrived safely at the shelter. Interviews with facility staff revealed that there was a lack of communication and coordination in handling the resident's discharge. The Social Service Director was not informed about the discharge until after the incident, and the Assistant Director of Nursing did not consult with the Social Service Director for the resident's placement. The facility's Director of Nursing admitted to not being familiar with the AMA policy for residents with mental illness and failed to document the medication order properly. The facility's Administrator acknowledged that the situation was intense and that they did not have all of the resident's previous psychiatric history, but admitted that they could have done better in handling the discharge.
Removal Plan
- The Medical Director reviewed and approved the updated changes to the Policy and Procedure for Out on Pass, to include, residents' discharge, and measures to take if a resident is out on pass and refuses to return to the facility.
- The Medical Director approved the updated changes to the Policy and Procedure for Discharging a Resident Without a Physician's approval (Against Medical Advice-AMA).
- The facility began In-service (education) training for Social Services and Licensed Nurses on Policies and Procedures for the following; Out On Pass, Safe Discharge AMA, by the Director of Nursing/Designee to be completed when employees return to work according to their schedule.
- At the time of admission, the physician will make the decision regarding the capacity (ability of the resident to make decisions). The results of the capacity determination will identify if the resident is responsible for decision making. The facility will ascertain if the resident has a responsible party or not, prior to admission. A new policy and procedure will be implemented for capacity. The Admission Packet includes the resident's capacity for making decisions and the responsible party who signs on behalf of the resident.
- Physicians will be asked to reassess their residents' capacity status as needed.
- The Out On Pass Policy was updated to state that if a resident is refusing to return to the facility from out on pass activity, residents' responsible party, primary MD and Psychiatrist will be notified.
- Every effort will be made by the staff to assist the resident to return to the facility. They will have a conversation with the resident on why they do not want to return to the facility. Social Services, the Administrator and Director of Nursing will be notified.
- If the resident is suspected to be a danger to self or others appropriate authorities will be notified to determine if a 5150 hold will be placed and the resident will be transferred to a psychiatric acute care hospital for further evaluation. If the resident is determined not to be a danger to self or others, he/she will be educated on the risks and benefits of leaving the facility against medical advice (AMA). As, it is the Residents Right to leave the facility AMA, the staff will follow guidelines of AMA policy and procedure.
- The facility began In-service training for Social Services staff and Licensed Nurses on Policies and Procedures for the following; Out On Pass, Safe Discharge AMA, by the Director of Nursing/Designee to be completed as employees return to work according to their schedule.
- A facility wide Capacity/Responsible Party audit was conducted to determine if there were any other residents found to have unknown responsibility status. At this time all residents have capacity identified and the Responsible Party identified. An audit was conducted by Social Services for other residents if they have fluctuating capacity. 18 residents were identified with fluctuating capacity. Out of the 18 identified, six residents did not have capacity status; they were referred to the public guardian. Four of those are still being processed and two have been processed and will move forward through the public guardian appointing process. Their physicians will be notified to reassess if they have capacity to make decisions on a quarterly basis.
- The care plans for those residents with fluctuating or no capacity will be revised to reflect the residents' capacity.
- The resident's physician will be notified of the request for AMA discharge. The physician will determine the need to release the resident AMA with or without medications. If the resident does not have capacity, they will not be sent with medications unless there is a Responsible Party present to take responsibility for the medication. If the resident is released with medications and it is expected that they will self-administer those medications, an assessment of the resident, will be conducted by the nursing staff to assure they have the ability to accurately self-administer those medications.
- Any resident who discharges AMA will be trained on self-administration of medications before they leave the facility. A Discharge Summary will be given to the resident with the directions for taking the medications. The resident will sign the Discharge Summary indicating that they have received self-medication administration training and understand the risks and benefits of taking the medications correctly. The facility staff will also sign the Discharge Summary, witnessing the resident's signature. The progress note will include all steps taken to foster the resident's highest practicable wellbeing because of the resident going out of the facility AMA.
- Licensed nurses will be in-serviced on the policy and procedure for self-administration of medications, training on self-administration of medications and disposition of remaining medications by the Director of Nursing/Designee using the teach back method or upon their next scheduled shift. Medications not given to the resident upon AMA discharge will be disposed of according to State and Federal regulations.
- The facility will ensure that any resident who leaves the facility AMA is given the best chance possible of succeeding outside of the facility by notifying the receiving facility, including shelters, the resident has requested to move to and that the shelter would be able to meet their needs. Social Services and licensed nurses will be in-serviced on notifying the intended location, assuring availability and capability to meet resident needs. Social Services will be responsible for notifying any shelter of the resident's request. Social Services will be in-serviced on Discharging a Resident Without a Physician's approval (Against Medical Advice-AMA) by the Director of Nursing/Designee.
- Social Services will be responsible for follow-up on any resident who went AMA to see if they arrived at their intended location, where practicable. Social Services and Licensed nurses will be in-serviced by the Director of Nursing/Designee.
- The facility has begun an audit of all residents with the inability to make decisions. Conservators/Responsible Party will be notified if one of their residents tries to seek a discharge (AMA). That is the conservator's/ Responsible Party's responsibility to make that decision. The facility will follow the conservators' decisions. The facility will follow its' policies and procedures for AMA Discharge and notification of Responsible Parties pending AMA discharge.
- Action Plans to manage reoccurrences of leaving the facility against medical advice (AMA) will be implemented in the Quality Assurance and Performance Improvement Committee.
Penalty
A resident with multiple complex medical conditions was discharged while her appeal was still pending, and before all necessary home equipment and support services were in place. The facility proceeded with the discharge after determining the appeal was filed outside the 10-day window, despite having received notice of the scheduled hearing. The resident was left without essential equipment and adequate caregiver arrangements, resulting in dependence on a family member for personal care.
A resident was transferred to the hospital without their comprehensive care plan goals included in the required documentation. Both an RN/Unit Supervisor and an LPN confirmed that care plan goals were not sent with residents during transfers, and this issue was reviewed with the DON.
A resident with schizophrenia and recent elopement attempts was subject to involuntary transfer and discharge procedures initiated by facility staff without the required physician documentation or orders. The DON completed the necessary forms at the direction of corporate staff, but the forms were not signed by a physician and lacked detailed medical justification. Hospital evaluation found no immediate safety concerns, and the resident's medical record did not contain physician progress notes or orders supporting the transfer or discharge.
A resident with complex psychiatric and medical needs was transferred to a hospital for evaluation after exhibiting aggressive behavior. Despite being cleared for return, the facility did not allow the resident to come back, failed to document the basis for discharge, and did not provide the required discharge notice or summary, in violation of facility policy and regulatory requirements.
The facility failed to communicate necessary information to receiving health care providers for two residents transferred to the hospital. One resident with intellectual disabilities and dementia showed symptoms requiring hospital transfer, but the facility did not document communication of care plan goals or advanced directives. Another resident with high blood pressure and depression was also transferred without documented communication of essential information. The Nursing Home Administrator confirmed these deficiencies.
A resident with multiple medical and cognitive conditions was issued a discharge notice for non-payment, but the facility did not provide a discharge summary, plan, or adequate notification to the resident, responsible party, or ombudsman. The discharge notice lacked a specific destination, and staff interviews revealed no finalized discharge plan or proper communication, contrary to facility policy.
Discharge Executed While Appeal Pending and Without Adequate Planning
Penalty
Summary
A resident was discharged from the facility while an appeal of her discharge was still pending. The resident had received a 30-day discharge notice due to nonpayment and was informed of her right to appeal. Documentation shows that the resident filed her appeal on what the facility determined was the 11th day after notice, rather than within the 10-day window, and the facility proceeded with the discharge prior to the scheduled hearing date. Both the facility and the resident had received notice of the upcoming hearing, but the discharge was carried out before the appeal was heard. The resident had multiple complex medical conditions, including chronic hepatic failure, COPD, chronic respiratory failure, heart failure, lymphedema, morbid obesity, dysphagia, depression, and anxiety. At the time of discharge, she required significant assistance with transfers, was dependent on a sit-to-stand lift, and used a wheelchair as her primary mode of mobility. Therapy and social services notes indicated that not all necessary equipment, such as the sit-to-stand lift and upright walker, were available at her home at the time of discharge. The resident also reported not having a finalized schedule for home health services and expressed distress about being dependent on a male family member for personal care, which she found undignified and uncomfortable. Facility records and interviews confirm that the discharge was executed despite the pending appeal and without all recommended equipment and services in place. The facility's policy requires a safe, orderly, and planned discharge, including ensuring the resident's needs are met at the discharge location. The resident's care plan and therapy recommendations highlighted the need for specific equipment and support, which were not fully arranged at the time of discharge.
Failure to Send Comprehensive Care Plan Goals During Resident Transfer
Penalty
Summary
The facility failed to include the resident's comprehensive care plan goals in the required documentation during a transfer to the hospital. Record review showed that one resident was hospitalized, and interviews with both a Registered Nurse/Unit Supervisor and a Licensed Practical Nurse confirmed that the care plan goals were not sent with the resident upon transfer. The surveyor discussed this concern with the Director of Nursing.
Failure to Obtain Required Physician Documentation for Involuntary Transfer/Discharge
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the required physician documentation was included in the medical record to support a resident's transfer and discharge rights. A resident with a history of schizophrenia and elopement behaviors was admitted to the facility and, shortly after admission, attempted to leave the facility twice. Following these incidents, facility staff initiated a Petition for Involuntary/Judicial Admission and a Notice of Involuntary Transfer or Discharge (IVD), citing the safety of individuals in the facility as the reason for the proposed transfer or discharge. However, the forms were completed by the Director of Nursing at the instruction of corporate personnel, and not by a physician. The IVD form indicated that the transfer was not an emergency, and the petition lacked detailed physician input or signature. Review of the resident's medical record and hospital documentation revealed that there were no physician orders for the involuntary psychiatric admission or for discharge. The hospital evaluation found no acute psychiatric or medical condition requiring intervention, and the petition from the facility was deemed invalid due to the lack of clear immediate safety concerns and improper completion. Additionally, the resident's electronic medical record contained no progress notes from a nurse practitioner or physician regarding the need for involuntary discharge or psychiatric admission, and behavioral monitoring documentation by CNAs was incomplete, only noting the resident as "not available." Facility policy requires physician confirmation and documentation in the medical record to support emergency transfers or discharges, as well as clear documentation of the danger posed by the resident. In this case, the required physician documentation and orders were absent, and the forms were not properly completed or signed by a physician, resulting in a failure to meet regulatory requirements for transfer and discharge rights.
Failure to Document and Notify Resident Discharge After Hospital Transfer
Penalty
Summary
The facility failed to ensure that a resident was not transferred or discharged without adequate reason and proper documentation. A resident with diagnoses including dementia, paranoid schizophrenia, major depressive disorder, legal blindness, and anxiety was transferred to a hospital for a psychological evaluation following aggressive and combative behavior, including breaking a window and being combative with staff. Despite being cleared medically and psychiatrically at the hospital, the resident was not allowed to return to the facility. The facility did not document the basis for the resident's discharge, nor did it provide the required discharge summary or notice to the resident or their representative. The care plan for the resident was marked as cancelled and resolved shortly after the transfer, and there was no evidence in the records of a formal discharge process or communication of the discharge decision. Interviews with facility administration and the resident's family confirmed that the resident was not permitted to return due to behavioral concerns, despite the facility's awareness of these behaviors at the time of admission. Facility policy states that residents must be permitted to return following hospitalization unless specific criteria are met and that not permitting a resident to return constitutes a discharge. The lack of documentation and failure to follow the required discharge process could result in residents not having the opportunity to appeal the discharge, as noted in the findings.
Failure to Communicate Resident Information During Transfers
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider for two residents who were transferred from the facility. Resident R47, who had diagnoses of intellectual disabilities, dementia, and major depressive disorder, was transferred to the hospital after exhibiting symptoms such as elevated blood pressure, right-sided facial droop, and left arm weakness. Despite the transfer, there was no documented evidence that the facility communicated the resident's care plan goals, advanced directive information, or specific instructions for ongoing care to the hospital. Similarly, Resident R76, who had diagnoses of high blood pressure, depression, and dementia, was transferred to the hospital due to elevated blood pressure and a headache. The facility also failed to document the communication of necessary information to the receiving health care provider, including the resident's care plan goals, advanced directive information, and resident representative information. During an interview, the Nursing Home Administrator confirmed the lack of evidence that the necessary information was communicated to the receiving health care institution for these two residents. This deficiency was identified based on a review of facility policies, resident records, and staff interviews.
Plan Of Correction
1. The facility is unable to go back and make certain that specific information was communicated to the receiving health care provider during resident transfers. 2. DON/designee to educate licensed staff on comprehensive transfer protocol regarding providing specific information to receiving health care provider and appropriate documentation on the event. 3. DON/designee to audit hospital transfers to ensure proper documentation is sent 5x/week for 2 weeks, then 3x/week for 2 weeks, and 1x/week for 2 weeks. 4. Results to be submitted to QAPI for review and approval.
Failure to Provide Proper Discharge Documentation and Planning
Penalty
Summary
The facility failed to properly discharge a resident by not providing all necessary information and documentation required for a safe and effective transition of care. The resident, who had significant medical and cognitive impairments including vascular dementia, major depressive disorder, type 2 diabetes with neuropathy, and bilateral below-knee amputations, was not his own responsible party. The facility issued a discharge notice for non-payment but did not document a discharge summary, discharge plan, or provide adequate notification to the resident, responsible party, or ombudsman. The discharge notice also lacked a specific address for the resident's discharge destination. Record review showed no evidence of discharge planning discussions or documentation in the nursing progress notes. Interviews with facility staff revealed that the discharge process was still ongoing, with no finalized plan or summary in place. The ombudsman and responsible party were not properly informed, and there was confusion among staff regarding the resident's discharge status and destination. The resident expressed concerns about not receiving sufficient help with his Medicaid application and uncertainty about his ability to return home, while the responsible party indicated the resident's previous home was uninhabitable and that family support was unavailable. Facility policy requires documentation of the basis for discharge and a plan to ensure a safe transition, but these steps were not followed. The lack of a documented discharge summary, plan, and proper notification could compromise the resident's continuity of care and transition to an appropriate setting, as the facility had not determined a safe discharge location or communicated effectively with all involved parties.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release August 26, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.