A resident with type 2 DM, a cardiac pacemaker, and dependence on staff for most ADLs was care planned to return home with HHC supports, including services from a specified home health agency starting shortly after discharge. However, the facility did not ensure that the home health referral was actually made and confirmed before discharge. The care coordinator stated they had not sent the referral and believed a former social worker had done so, and later learned from the agency that no referral had initially been received. The home health agency reported that the referral was not received until several days after discharge, at which point services were initiated, resulting in a delay between discharge and the start of home health care.
A resident with dementia, multiple comorbidities, and an ileostomy was determined by two MDs to lack capacity for medical decision-making and was left without an active POA after the designated family POA resigned in writing. Despite this, the facility had the resident sign a Medicare non-coverage notice, did not complete the care-planned home safety visit, and discharged the resident home based on the resident’s request and an assumption that the former POA would still provide support. Social services documented planned home health (PT, OT, nursing, HHA) and a PCP visit, but the listed home health agency later reported the resident was never evaluated or enrolled, and a family member found the resident at home alone in poor condition. The NHA and SSD acknowledged they did not seek emergency guardianship and could not confirm the resident’s safety or that appropriate support services and a patient representative were in place at discharge, and they did not inform a sister facility that the resident lacked a guardian or POA when asked for information.
A resident with quadriplegia, depression, and schizoaffective disorder was sent to a hospital for psychiatric evaluation after exhibiting behavioral changes. Hospital records show the resident was cleared to return and repeatedly stated they only wanted to go back to their prior facility, but the DON informed the hospital that the physician wanted the resident transferred to a sister facility and that the home facility would not accept the resident back. The resident reported their belongings had already been moved to the sister facility, and hospital notes documented the resident’s refusal to go there. Facility progress notes did not document any agreement by the resident to transfer, any police arrests, or changes in leave-of-absence status, despite the facility’s policy requiring notice, preparation, and information about appeal rights for transfers and discharges.
A cognitively intact resident with chronic hypoxic respiratory failure and morbid obesity was transferred to a hospital with unclear and poorly documented reasons in the EMR, which only noted constipation and an O2 saturation in the low 80s. The ADON acknowledged that the discharge was not properly documented and that the reason for sending the resident out was unclear. After the resident became medically stable in an out-of-state hospital, the resident, hospital CM, and Ombudsman reported that the resident wished to return and had been educated on the risks of using BiPAP instead of AVAP, but the NHA repeatedly delayed or refused readmission, citing an inability to manage AVAP and daily ABGs despite a sister facility’s experience with AVAP. A hospital-arranged transport returned the resident to the facility after a long trip, but staff, reportedly under the NHA’s direction, did not open the door or accept the resident, forcing a return trip to the hospital. These actions conflicted with the facility’s own transfer/discharge policy requiring clear physician documentation, appropriate criteria for transfer, and proper notice and process.
A resident with hemiplegia and dependence for transfers was discharged home without effective discharge planning or documentation. The care plan called for coordinated discharge orders, home health and therapy referrals, and DME, but social services did not clearly assist with the insurance appeal process, did not document a comprehensive discharge plan, and did not arrange post‑discharge services. The family member reported receiving short‑notice of discharge, no caregiver education, no referrals for home health or outpatient therapy, and no help obtaining needed DME such as a wheelchair and hospital bed. Nursing staff were unaware of the exact timing of discharge and the ambulance left without the printed discharge paperwork. Therapy staff were not informed in time to complete a discharge assessment and stated the resident remained dependent with transfers and unsafe to stand. The discharge packet later found in a shred box was incomplete, lacking transportation details, instructions review, signatures, and key contact information, demonstrating that the resident was discharged without a safe, orderly, and well‑documented transition plan.
Failure to document AMA discharge information: A resident with muscle weakness, difficulty walking, and impaired cognition left the facility AMA, and the record showed only a later SW note stating the nurse manager was notified, the resident returned home, HHC was arranged, and the family was told to follow up with the PCP. No other progress note was found, the DON said the facility did not use AMA forms, and an LPN stated physician notification and education occurred but no progress note was completed.
A resident with aphasia, right‑sided hemiplegia, dementia with agitation, depression, and moderate cognitive impairment had episodes of loud, combative behavior, including kicking a door, shaking a fist at others, and later punching another resident’s arm. After being sent to the hospital twice for behavioral evaluation, hospital staff determined on both occasions that the resident did not meet criteria for medical or psychiatric admission and discharged him back. Facility staff, including the UM and liaison, reported that management had directed that the resident not be accepted back due to perceived danger to residents and staff, and EMS was not allowed to re‑enter the building with the resident. No formal eviction or discharge notice was issued, the Ombudsman was not notified, and required transfer documentation was missing, despite the facility’s own guidelines requiring notice, preparation, and appeal rights. The resident’s family was told he could not return and was asked to remove his belongings, while the resident remained in the hospital pending alternate placement.
A resident with multiple serious comorbidities and intact cognition was discharged home despite repeatedly stating she could not safely enter her house or care for herself, and despite her family’s clear objections and inability to prepare the home environment. Staff, including RNs and therapy, documented and reported that the resident was distraught, crying, and fearful about going home, and one RN refused to sign the discharge paperwork due to safety concerns. The facility proceeded with discharge after managed care coverage ended, requiring advance private payment and refusing a personal check, while a second-level insurance appeal was still in process. On arrival home, the transport driver could not get the resident’s wheelchair through the doorway and noted additional obstacles inside, leading the family to call an ambulance and the resident to be sent to the hospital, demonstrating that the discharge planning process did not ensure a safe and appropriate transition.
A resident with severe dementia, significant behavioral symptoms, and a known history of aggression and wandering was admitted after hospital evaluation, despite extensive pre-admission documentation of behavioral issues. Following multiple episodes of exit-seeking and physical aggression toward staff, the resident was transferred to the hospital, and when EMS later attempted to return the resident, nursing staff—under orders from the DON and Administrator—refused readmission, stating the facility could not meet the resident’s needs and issuing a verbal "do not return" directive. The resident’s representative was informed only verbally that the resident would not be accepted back, and the ombudsman was contacted by phone without written notice. Review of records showed incomplete transfer documentation, lack of required written involuntary discharge notices and appeal information, and outdated policies referencing obsolete regulations, despite a bed-hold/readmission policy that called for holding a bed and readmitting residents with an expectation of return unless specific criteria were met.
A resident with multiple psychiatric and medical diagnoses, who was cognitively intact, was issued immediate involuntary discharge paperwork for alleged repeated threats toward staff and other residents. Police were involved after the resident called 911, and the resident was later transported to the ED under a court-appointed petition. When the hospital attempted to return the resident, facility staff stated the resident would not be readmitted and could instead go to a local motel, and the hospital ultimately discharged the resident to the community. Although facility forms cited danger to the safety and health of others as the reason for transfer/discharge, the medical record lacked physician documentation that the transfer/discharge was necessary for these safety concerns.
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