Failure to Readmit Resident Post-Hospitalization
Summary
The facility failed to permit a resident to return following hospitalization, which was evident for one of six residents. The resident was initially transferred to the hospital for severe dysphagia evaluation and possible feeding tube placement. Despite the hospital's assessment that a feeding tube was not necessary, the facility refused to readmit the resident, citing care needs exceeding their current capacity. The facility did not provide the resident or their representative with a written notice of discharge, including notification of appeal rights, nor did they notify the Long-term Care Ombudsman. The facility's policies on admissions and discharge planning did not address the protocol for residents transferred to the hospital but not accepted back. The resident, who was cognitively intact, had been admitted with a diagnosis that included dysphagia. The facility's interdisciplinary team, including a medical doctor, determined that the resident was at high risk for aspiration and recommended hospital transfer for further evaluation. However, the facility did not follow the required procedure for discharge notification, failing to issue a 30-day notice with appeal rights. Interviews with the resident's representative and facility staff revealed that the decision not to readmit the resident was based on the facility's assessment of the resident's care needs and risk for aspiration. The medical team, including the medical director, reviewed the hospital's patient review instrument and decided against the resident's return. Despite discussions with the resident's family about the risks and necessary precautions, the facility did not document or communicate the discharge decision appropriately, leading to the deficiency.
Plan Of Correction
Plan of Correction: Approved March 24, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Immediate Corrective Action 1. Resident #1 was transferred to the hospital on [DATE] and did not return to the facility. 2. The Director of Social Service was given an educational counseling and a 1:1 inservice on discharge protocol emphasizing that the resident / resident representative and the Long-term Care Ombudsman is notified of the discharge in writing, including notification of appeal rights. II. Identification of Others 1. The Facility respectfully acknowledges that all residents have the potential to be affected by this deficiency. 2. The Director of Social Service compiled a list of residents in the last 30 days who have been discharged from the facility. The list was reviewed to ensure that each resident / resident representative in addition to the Long Term Care Ombudsman was notified of the discharge in writing, including notification of appeal rights. 3. No other issues were identified. III. Systematic Changes 1. The Administrator, Medical Director, DNS and Director of Social Service reviewed and revised the policy on “Discharge Planning: Discharge Notification to Resident / Family” to include a protocol for a resident who was transferred to the hospital from the facility but is not being accepted back into the facility. The protocol includes that the resident / resident representative in addition to the Long Term Care Ombudsman will be notified of the discharge in writing, including notification of appeal rights. 2. The Director of Social Service and the social workers will be in-serviced on the revised policy “Discharge Planning: Discharge Notification to Resident / Family” by the administrator / designee with emphasis on ensuring that each resident / resident representative in addition to the Long Term Care Ombudsman are notified of the discharge in writing, including notification of appeal rights. 3. The Administrator, Medical Director, DNS and Director of Social Service reviewed the policy on “Admission Process” including not being able to accept a resident if the facility cannot provide adequate or appropriate care for that resident and found it to be compliant. 4. The Director of Admissions, Director of Social Service and the social workers will be in-serviced on the policy by the administrator regarding “Admission Process” by the administrator / designee with emphasis on appropriate admissions to the facility depending on the resident’s level of care. 5. A copy of the Lesson Plan and Attendance is filed for reference and validation. IV. Quality Assurance 1. The Administrator and Director of Social Service created an audit tool to ensure that the resident / resident representative as well as the Long Term Care Ombudsman is notified in writing regarding the discharge including the notification of appeal process. 2. Audits will be done by the Director of Social Service/Designee on 10 random discharges weekly x 4 weeks, 10 random discharges monthly x 3 months and 10 random discharges quarterly thereafter. 3. Audits with negative findings will have an immediate corrective action taken by the Director of Social Service and reported to the Administrator for review & follow up. 4. Audit findings will be presented to the QA Committee quarterly by the Director of Social Service. V. The Administrator will be responsible to ensure correction of this deficiency by 4/7/2025.
Penalty
A resident with Medicaid coverage was transferred to the hospital for behavioral issues, and the facility did not provide required written notice of bed-hold or readmission rights. Despite policy allowing a 15-day bed hold, there was no documentation of informing the resident or representative, nor evidence of clinical reassessment or discharge planning. The facility imposed additional conditions for return and did not coordinate with the hospital for the resident's readmission.
A resident with multiple medical and cognitive issues was not permitted to return to the facility after a hospital transfer, despite not exhibiting behaviors that endangered herself or others. Facility staff cited safety concerns due to the resident's confusion and attempts to leave, but there was no physician documentation or evidence that the facility could not meet her needs. The refusal to readmit led to the resident remaining in the hospital unnecessarily.
A resident with complex medical and behavioral needs was not permitted to return to the facility after hospitalization for acute confusion and infection. Despite stabilization and no evidence of ongoing aggression, the administrator informed hospital staff and the resident's family that the resident would not be allowed back, contrary to facility policy and regulatory requirements. Staff interviews indicated the resident's behaviors were related to his medical condition, and the resident was not given the option to return.
A resident was transferred to the hospital due to behavioral issues without being issued an involuntary discharge notice or having required transfer documentation and care plan information sent. The DON made the decision to transfer the resident, and hospital staff reported that no paperwork, belongings, or bed hold notice were provided, and the resident was not assessed by facility psychiatric services or a physician prior to transfer.
A facility failed to re-admit a resident after hospitalization, despite the resident being medically stable and off restraints. The resident, with a history of aggressive behavior and multiple medical conditions, was initially sent to the hospital due to increased aggression. The facility's DON and NHA refused re-admission, citing inadequate documentation, and did not collaborate with the hospital to address the resident's needs, leading to a deficiency.
A facility failed to document the decision-making process and notify a resident's family about appeal rights after not allowing the resident to return post-hospitalization. The resident, with a history of bipolar disorder, anxiety, and depression, exhibited erratic behavior following ECT treatment. Staff noted the behavior was uncharacteristic, but the facility did not document the clinical decision-making or consult a provider, nor did they provide necessary appeal information to the family.
Failure to Provide Bed-Hold Notice and Permit Return After Hospitalization
Penalty
Summary
The facility failed to implement and document required procedures regarding bed-hold policies and resident rights for a Medicaid-covered resident who was transferred to the hospital for behavioral concerns, including physical aggression toward staff. There was no evidence that the resident or their representative received a written notice of the facility's bed-hold or readmission policy at the time of transfer, nor any documentation indicating acceptance or declination of a bed hold. Despite the facility's policy allowing a 15-day bed hold for Medicaid residents, the clinical record lacked any indication that the resident was informed of their rights to return or that the facility planned for the resident's readmission. Following the resident's transfer, social service notes documented attempts to place the resident in other facilities, all of which declined. Hospital staff repeatedly requested the resident's readmission, but the facility's corporate admissions representative imposed conditions for return that were not part of the documented policy. There was no evidence of a clinical reassessment or evaluation of the facility's ability to meet the resident's needs, nor any transfer or discharge planning documents. The Nursing Home Administrator and Director of Nursing confirmed the decision not to readmit the resident due to safety concerns, but there was no formal documentation of a review of the facility's capacity to care for the resident upon potential return.
Failure to Permit Resident Return After Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after a hospitalization, in violation of federal requirements for permitting residents to return to the facility following a hospital stay or therapeutic leave. The resident, who had been admitted with multiple diagnoses including stroke, depression, and muscle weakness, was described as friendly but disoriented, requiring staff assistance for personal care, eating, transfer, and ambulation. After admission, the resident eloped from the facility and was found at another facility across the street. Upon return, the resident was placed on one-on-one supervision and later sent to the emergency room for evaluation. Despite repeated requests from the hospital, the facility refused to readmit the resident, citing concerns about the resident's safety due to confusion, agitation, and a tendency to attempt to leave the facility. Interviews with facility staff, including the Administrator and DON, revealed that the decision to refuse readmission was based on the belief that the resident was not safe at the facility, particularly given its proximity to a busy street. However, staff interviews and documentation indicated that the resident did not exhibit physical aggression, agitation, or behaviors that endangered herself or others. The resident was described as confused, talking about wanting new slippers, and attempting to get up from her wheelchair, but not combative or aggressive. The facility's own policies required that discharges or refusals to readmit be based on documented evidence that the resident's needs could not be met or that the resident posed a danger to themselves or others, with physician documentation supporting such decisions. In this case, there was no documentation from a physician indicating that the resident's needs could not be met or that transfer was necessary. The DON acknowledged the lack of clinical records supporting the decision and agreed that interventions such as a wander guard and adequate supervision might have prevented the elopement and subsequent transfer. The failure to permit the resident's return resulted in the resident remaining unnecessarily in the hospital while awaiting placement.
Failure to Permit Resident Return After Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after hospitalization, in violation of its own policy and federal regulations regarding resident rights to remain in the facility unless specific criteria for discharge are met. The resident in question had a complex medical history, including osteomyelitis, paraplegia, anxiety disorder, and an ileostomy, and was admitted and readmitted to the facility prior to the incident. Documentation showed that the resident experienced an acute episode of confusion, agitation, and combative behavior, which coincided with a urinary tract infection, sepsis, and metabolic encephalopathy. Staff documented that the resident was resistant to care, removed his colostomy bag, and swung a trapeze bar, but interviews with staff indicated that he had not been physically aggressive toward other residents and that his behavior was likely related to his acute medical condition. On the day of the incident, the resident was sent to the hospital for evaluation due to increased confusion and agitation. The facility completed an involuntary discharge notice, citing safety concerns and an inability to meet the resident's needs. The administrator delivered the resident's belongings and attempted to have the resident sign discharge paperwork at the hospital, despite being informed by hospital staff that the resident was not cognitively able to understand or sign the documents. Hospital case management notes and interviews confirmed that the administrator stated the resident would not be allowed to return to the facility, and this was communicated to both the hospital and the resident's family member. Multiple interviews with facility staff, hospital staff, the ombudsman, and the resident himself revealed that the resident was not offered the opportunity to return to the facility after his medical condition stabilized. The administrator maintained that the resident refused to return, but both the resident and his family member stated they were not given the option. The facility's actions were not consistent with its policy or regulatory requirements, as the resident's acute behavioral episode was related to a treatable medical condition, and there was no evidence that the facility could not meet his needs after stabilization.
Failure to Issue Involuntary Discharge Notice and Provide Required Transfer Documentation
Penalty
Summary
The facility failed to issue an involuntary discharge notice to a resident prior to transferring the resident to the hospital, which resulted in the resident not being informed of their legal rights as required for residents in long-term care. The resident, who had been admitted to the facility and later transferred to the hospital due to behaviors such as wandering, aggression, and combativeness, did not have documentation in their medical record indicating that care plan goals or required transfer information were sent to the hospital. Additionally, there was no evidence that the resident was assessed by facility psychiatric services or a facility physician prior to the transfer. Interviews with facility staff, including the DON and hospital liaison, revealed that the decision to send the resident back to the hospital was made by the DON, and the hospital was informed that the resident would not be returning to the facility. The hospital social workers confirmed that no paperwork, belongings, or bed hold notice accompanied the resident upon transfer, and the facility medical director stated they had no input in the decision. The lack of proper documentation and communication regarding the resident's transfer and discharge process led to the deficiency.
Facility Fails to Re-Admit Resident Post-Hospitalization
Penalty
Summary
The facility failed to re-admit a resident after a change in condition, which was identified as a deficiency. The resident, who had a history of morbid obesity, transient cerebral ischemic attack, hypertension, cognitive communication deficits, diabetes, and a urinary tract infection, exhibited aggressive behaviors such as kicking, scratching, yelling, and refusing meals and medications. On March 3, 2025, the resident was sent to the hospital due to increased aggression and was later diagnosed with an acute kidney injury and treated for a urinary tract infection. Despite the hospital's report that the resident no longer required Haldol or physical restraints, the facility refused to re-admit the resident. The hospital social worker documented that the resident had been off restraints for over 60 hours and was medically stable for discharge. However, the facility's Director of Nursing (DON) and Nursing Home Administrator (NHA) expressed concerns about the resident's stability and refused re-admission, citing inadequate documentation of the resident's condition. The facility did not provide documentation to support their decision not to re-admit the resident, nor did they collaborate with the hospital to address the resident's needs. Interviews with the DON and NHA confirmed the lack of documentation and collaboration, which contributed to the deficiency. The facility's actions were not in compliance with the regulatory requirements for permitting residents to return after hospitalization.
Plan Of Correction
The facility does and shall ensure to permit residents to return to the facility after hospitalization/therapeutic leave. The facility does and shall ensure to follow the bed hold policy permitting residents to return to the facility after hospitalization/therapeutic leave. The facility does and shall ensure to document conversations with the hospital and family regarding transfer back to the facility. Monitoring/random review will be conducted by admission director or designee and social services 1 time weekly for 3 months with findings reported to the CQI Committee for a period deemed appropriate by the CQI Committee.
Failure to Document and Notify Regarding Resident's Return Post-Hospitalization
Penalty
Summary
The facility failed to ensure proper documentation and notification procedures were followed when they did not allow a resident to return after hospitalization. The resident, who had diagnoses including bipolar disorder, anxiety, and depression, was noted to have intact cognition with a BIMS score of 14 out of 15. After an electroconvulsive therapy (ECT) treatment, the resident exhibited erratic behaviors such as urinating on the floor and undressing in public areas, which were out of character according to staff interviews. Despite these behaviors, the facility did not document the clinical decision-making process regarding the resident's inability to return, nor did they consult with a provider or specify which needs they could not meet. Additionally, the facility failed to provide the resident's family with necessary information regarding appeal rights, including contact details for the entity handling such requests and assistance in completing appeal forms. Interviews with staff revealed that the resident was generally pleasant and cooperative prior to the incident, and the sudden change in behavior was unexpected. The facility's administrator admitted to lacking documentation related to the decision-making process and mistakenly believed that appeal notices were unnecessary if the resident was out of the facility for more than ten days.
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