A resident with atrial fibrillation, heart failure, and COPD was discharged home with documented discharge instructions and medications, but the Social Services section of the Discharge Transition Packet was left blank, and no home health or therapy services were arranged. Facility policy required a post-discharge care plan and coordination of ongoing services with the resident and representative. The resident’s spouse later contacted the facility reporting that needed services had not been set up, and a social services staff member admitted that arranging home care and therapy was missed when they were off duty, resulting in incomplete discharge planning and information.
A resident with schizoaffective disorder, depression, and anxiety was not permitted to return after hospitalization, despite a facility policy requiring residents be allowed to return from hospital or therapeutic leave and no documentation that the facility could not meet their needs. Clinical notes showed the resident had expressed suicidal ideation, was sent to the ER, briefly returned, again reported severe depression and risk of self-harm, and was then transferred to an inpatient mental health hospital. The DON and a physician reported the facility did not allow the resident to return because they lacked staff for needed 1:1 monitoring, and the NHA confirmed the resident was denied readmission without any documented reason or date in the clinical record.
The facility failed to create and implement individualized discharge plans for two residents who expressed a desire to return to the community or home. For one cognitively intact resident with schizophrenia, the MDS Section Q showed no active discharge planning, and the care plan lacked goals, interventions, or documentation of barriers, despite the resident’s stated wish to live with a family member and the DON’s knowledge of family refusal and complex history. For another resident with dementia and moderate cognitive impairment, the MDS also showed no active discharge planning, and the care plan did not address discharge goals or options, even though the resident had a prior unsuccessful discharge, continued to express a desire to go home, and the SSD was aware of safety concerns and an uninhabitable home environment. The NHA and DON could not provide documentation of individualized discharge care plans for these residents.
A resident with chronic respiratory failure, morbid obesity, and type 2 DM requested hospital evaluation and was transferred to the hospital of their choice. The facility’s bed hold policy stated that a bed must be available for a resident’s return when away for hospitalization or therapeutic leave. After the resident was medically cleared for discharge, the hospital case manager contacted the facility about readmission, but the facility refused, claiming it could not meet the resident’s care needs. There was no documentation in the clinical record to support that the facility was unable to meet those needs, and the Administrator and DON confirmed the resident was not allowed to return.
A resident with multiple chronic conditions and intact cognition was discharged home, via a scheduled dialysis appointment, without receiving discharge instructions, prescriptions, or personal belongings, despite facility policy requiring a discharge transition packet for residents going to a private residence. Documentation showed that the RN signed the discharge summary and medication instructions later that evening, after the resident had already left, and there was no record that instructions or prescriptions were offered or refused. The administrator confirmed the resident should have received discharge instructions and prescription information, and the resident’s representative did not obtain the discharge paperwork until later that night, demonstrating a breakdown in the discharge process.
A resident admitted after a fall with a traumatic brain bleed consistently expressed a goal of remaining for LTC due to inability to manage stairs, living alone, and needing assistance with daily care, and this goal was documented by the IDT, social services, therapy, and a CRNP. Despite this, the resident later received a NOMNC and was discharged home without documented follow-up to address the change in plan or ensure safety. Therapy services were not timely updated about the shift from LTC to home discharge and did not provide training on home-related tasks or stair negotiation, even though the resident had multiple stairs at home. The case manager did not notify the insurer of the goal change, and the resident was discharged without written medication instructions specifying which medications to take, at what times and dosages, or which to discontinue.
A resident who was cognitively intact, incontinent, and at risk for pressure ulcers developed full-thickness moisture-associated skin damage to the sacrum and had a physician’s order for daily cleansing and Medi-honey application. Although treatment was documented on the TAR prior to discharge, the discharge instructions marked wound care as not applicable, and the drug disposition form did not show that Medi-honey was sent home. The resident was discharged home with home health after staff reviewed medications and instructions with family, but there was no documentation that wound care instructions or Medi-honey were provided, as confirmed by the NHA.
A resident with dementia, repeated falls, and muscle weakness was discharged without sufficient preparation or documentation to ensure a safe transition home. The facility did not confirm that home health or private duty services were arranged, failed to include key information in the discharge summary, and did not document a review of the discharge plan with the resident or representative. Essential details about the resident's living arrangements and recent health events were also missing from the records.
A resident with dementia was transferred to another facility due to behavioral issues and unmet needs, but the required physician documentation detailing the necessity of the transfer, unmet needs, attempts to address those needs, and services at the receiving facility was not present in the clinical record.
A resident with multiple medical conditions and a goal to return home was discharged without a documented discharge plan, physician's order, or post-discharge plan of care. The facility did not include discharge planning in the care plan or provide required documentation to the resident or caregiver, as confirmed by the DON and review of records.
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