Failure to Involve Conservator and IDT in High-Risk Resident’s Discharge to RCC
Summary
The deficiency involves the facility’s failure to ensure safe and appropriate discharge planning for a resident who was a Regional Center client with schizoaffective disorder bipolar type, unspecified psychosis, anxiety disorder, seizures, anemia, and severe cognitive impairment. The resident’s face sheet identified a conservator as the responsible party, and the MDS dated 11/19/2025 documented severely impaired cognitive skills for daily decision-making and dependence on staff for ADLs, with no ability to ambulate independently. The resident had documented high elopement risk and fall risk, including balance problems and decreased muscular coordination. Social Services documentation from 11/10/2025 indicated the resident came from a homeless environment and might need additional help once discharged home with the support of the conservator. An IDT conference on 11/14/2025 included the conservator by phone, but no discharge planning was discussed at that time, and the notes indicated the bed hold policy and discharge plan would be reviewed with the responsible party/conservator. On 1/28/2026, a physician’s order was obtained to discharge the resident to a recuperative care center (RCC). A progress note timed at 1:20 p.m. on that date documented that the resident was discharged and picked up by EMT personnel, with standard safety checks such as identity verification, confirmation of transfer destination, attachment of transfer documents, and securing the resident on a gurney. The same note indicated that a voicemail was sent to the conservator notifying them of the transfer, but there was no documentation of prior discussion, involvement, or consent from the conservator regarding the discharge plan or the choice of RCC. Social Services Staff stated that the resident was conserved under a Public Guardian and that the facility did not discuss the discharge planning or transfer to the RCC with the conservator, and that no IDT meeting was held related to the discharge plan prior to discharge. The DON stated that she and Social Services decided to transfer the resident to the RCC because the resident did not meet skilled criteria and needed a lower level of care where medications would be managed, and acknowledged that the conservator was not involved in the discharge planning or discharge and that there was no IDT meeting conducted for this discharge. The facility also failed to ensure adequate communication and clinical handoff to the receiving RCC. LVN 1 described the expected discharge process as including obtaining a physician’s order, performing a skin assessment, notifying the family or conservator, preparing discharge paperwork, printing the face sheet and medication summary, and contacting the receiving facility. LVN 1 stated these steps were not fully completed for this resident’s discharge, that he was unable to communicate with the conservator or the receiving facility, did not communicate with a receiving nurse, did not perform medication reconciliation, and did not endorse the resident’s medical history to the receiving facility. He reported that paperwork was handed to EMT personnel at the time of discharge and that he failed to verify the type of setting at the RCC to ensure it could meet the resident’s needs. Subsequently, EMS and hospital records documented that the resident was found wandering in the street in the early morning hours, not alert or oriented, with insect eggs on her clothes and hands, and was transported to a general acute care hospital where she was admitted with acute psychosis and altered mental status. Interviews with the conservator, CNA staff, and review of the facility’s discharge planning policy further confirmed that the resident’s discharge occurred without the required involvement of the conservator, without an IDT discharge planning process, and without appropriate clinical communication to the receiving RCC. The facility’s own policy on discharge planning required the Social Services Director or designee to be involved in discharge planning to ensure a safe discharge and successful transition to the next level of care or return home, working with the IDT, physician, resident, and resident’s representative. The policy specified that discharge planning services and any changes to the discharge plan were to be discussed with the resident and, if indicated, the resident’s representative, and documented in the medical record. In this case, interviews and record review showed that the conservator was not involved in selecting the RCC or consenting to the discharge, that no IDT meeting was held to assess the resident’s cognitive, medical, physical, and psychosocial needs prior to discharge to a lower level of care, and that the RCC was not properly notified of the resident’s diagnoses, medications, history of wandering, and risk for falls and seizures prior to transfer. These actions and omissions constituted the deficient practice cited under F-627 for failure to ensure a safe and appropriate discharge for this resident.
Removal Plan
- The DON/designee conducted an immediate clinical review of Resident 1’s status in collaboration with the GACH, including medication reconciliation and continuity of care.
- The IDT (Social Service, DOR, DON, ADON/QA Nurse, DSD, MDS Nurse) met to review root cause analysis and ensure discharge planning criteria/process compliance.
- The IDT (SSD, DON, ADON) conducted a facility-wide review of discharges, focusing on level of care determination, IDT involvement, legal representative notification/consent, safe discharge destination, and medication reconciliation/continuity.
- Require licensed nursing staff to notify the SSD of all resident discharges and have discharge information communicated to the SSD and reviewed during the weekly discharge planning meeting (including assessment of cognitive impairment, elopement risk, behavioral symptoms, conservatorship/legal representative involvement, and discharge planning), with variances corrected immediately.
- Require DON or designee to provide final authorization prior to discharge.
- During weekends/when SSD and DON are not physically present, require the Nursing Supervisor to review discharge documentation, confirm completion of required steps, and notify the SSD and DON for follow-up review.
- Implement a Hard Stop Discharge Protocol using a standardized interdisciplinary discharge checklist; no resident may be discharged until all checklist steps are completed.
- Require final approval by the Administrator or DON for all planned discharges to lower levels of care (including RCFE, ALF, ILF, and recuperative care) upon completion of the Hard Stop checklist.
- Require discharge planning to begin at baseline admission and be reviewed at least 30 days prior to projected discharge, again 7 days prior, and prior to the day of discharge.
- Assign QA Nurse responsibility for resident assessment and participation in the discharge process.
- Assign IDT (SSD, DOR, DON, DSS, QA) responsibility for reviewing discharge planning.
- Assign DON/QA/DON designee responsibility for reviewing clinical readiness and safety prior to discharge.
- Require licensed nursing staff to provide a complete handoff to the receiving provider/facility at discharge (clinical status, medications, care needs, follow-up requirements) and document the handoff in the medical record.
- Require SSD and licensed nursing staff to notify the resident’s guardian/responsible party regarding discharge planning, provide discharge destination options, and document preferences/consent in the medical record.
- Assign SSD responsibility for all discharge notices and documentation (notify resident/guardian/responsible party, document discharge plan and chosen destination, maintain related forms/communications in the medical record, ensure timely completion).
- Require Nursing Supervisor or licensed nursing staff to provide a complete handoff report to the receiving facility at discharge (clinical status, medications, care needs, behavioral considerations, follow-up requirements) and document it in the medical record.
- Require SSD to complete post-discharge follow-up/wellness check within 72 hours to confirm safe arrival, medication/care management, identify concerns, and document follow-up actions.
- Provide in-service training to the DON and Administrator on the Policy of Safe Discharge Planning, including the Hard Stop Discharge Protocol, interdisciplinary responsibilities, resident safety considerations, and compliance monitoring.
- Provide 1:1 in-service and competency validation with the SSD on the Policy of Safe Discharge Planning, including the Hard Stop Discharge Protocol, interdisciplinary responsibilities, resident safety requirements, and documentation expectations.
- Educate all licensed nurses, Social Services staff, and IDT members on CMS discharge requirements, resident rights, safe transitions of care, documentation expectations, legal representative notification, and high-risk discharge criteria; provide training by DON and SSD with attendance logs; include in new hire orientation.
- Audit all resident discharges using the Hard Stop Discharge Checklist (daily for first 2 weeks, weekly for next 4 weeks, then monthly) through QAPI to ensure ongoing compliance.
- Ensure on the day of discharge the licensed nurse provides a complete report/handoff to the receiving facility prior to transfer.
- Have Medical Records review audit findings and report results to DON/ADON/QA team; correct discrepancies timely; report results to the QAPI Committee by DON and SSD.
- Incorporate the discharge process into the facility’s QAPI program, including tracking/trending discharge variances, identifying root causes, implementing corrective actions, and reporting findings to leadership, with a performance goal of 100% compliance.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with cognitive and mental health diagnoses, who had previously expressed a desire to remain in LTC, exhibited an episode of aggressive behavior that led to an involuntary emergency mental health examination and transfer to a hospital. The facility’s documentation shows the DON and provider described the behavior as dangerous and initiated the transfer, but the clinical record lacked evidence that a bed-hold policy was offered at the time of transfer. Hospital records indicated the resident was calm, oriented, medically cleared, and did not meet criteria for continued involuntary psychiatric placement, and he was deemed ready for discharge. When the hospital sought to return the resident, the DON, Administrator, and Admissions Director reported that facility leadership and regional management decided not to accept him back or to any sister facilities, without documented basis for discharge, resulting in his placement at another nursing home approximately 73 miles from his family.
A resident with CHF, COPD, morbid obesity, chronic wounds, and total bowel/bladder incontinence was discharged home by stretcher despite being a mechanical-lift resident who could not walk or toilet independently. Home health was not in place, the family reported difficulty reaching SW, and the resident was discharged without an AMA notice or Ombudsman notice. She soiled herself at home, could not clean up, and was hospitalized shortly after for CHF exacerbation and fluid overload.
A resident with dementia, TBI, and prior severe cognitive impairment later became able to clearly express that she wanted to go home with Family Member D, but the care plan did not show updated discharge goals once she stabilized. Staff across nursing, Social Services, Activities, and administration knew she repeatedly voiced this preference, yet the chart did not show action to support her discharge wishes. The record also showed confusion about an MPOA that was not signed by the resident and no physician certification that she lacked competence to make her own health care decisions.
Failure to Allow Return After Hospital Transfer: A resident was transferred to the ER for altered mental status and increased confusion, but the facility did not provide a transfer/discharge notice and did not allow the resident to return after the acute hospitalization. The DON stated the decision not to permit return was financial, while the business office manager believed it was due to insufficient staffing. The facility policy stated residents transferred to acute care will be permitted to return upon discharge, and not permitting return constitutes a discharge.
Two residents experienced inappropriate and poorly managed discharges. One resident with acute PE, acute respiratory failure, DM2, affective disorder, and Parkinson’s disease was discharged to an ALF with transportation arranged through an outside company, but the transport request was later canceled and not confirmed by staff. After being moved from her room to an activities area and repeatedly told her ride was coming, she left the building in her wheelchair without staff awareness and was later found on the roadside and taken to the ED. Another resident with degenerative disc disease, DM2 due to other mental disorder, and adjustment disorder was transferred to another nursing home without a documented medical reason, without a 30‑day written notice, and with a discharge order lacking reason, level of care, or assistance needs. He reported being told he would be evicted if he did not choose a facility, refused to sign the transfer notice, and ultimately was sent to a different nursing home than the one he chose, later having to arrange and pay for his own transportation after the receiving facility would not take him back.
A resident with polyneuropathy, DM2, UTI, and HTN was discharged without a reconciled med list, discharge paperwork, or her prescribed meds, including pain meds. The discharge summary had no current meds listed, the signed discharge instruction form was not found in the chart, and the resident reported she went overnight without meds until the discharge planner delivered them the next morning. Staff accounts conflicted about whether discharge instructions and meds were reviewed and provided.
Failure to Permit Resident’s Return and Inadequate Discharge/Bed-Hold Process After Psychiatric Evaluation
Penalty
Summary
The deficiency involves the facility’s failure to allow a resident to return following a hospitalization and involuntary mental health evaluation, and failure to follow required transfer, discharge, and bed-hold procedures. The resident had been admitted with diagnoses including problems with social environment, mild cognitive impairment due to unknown origin, a condition with mixed features, and an adjustment disorder with mixed anxiety and depressed mood. A quarterly MDS showed intact cognition and no physical or verbal behavioral symptoms directed toward others at that time. The resident’s care plan documented that he wished to remain in LTC at the facility and identified goals related to managing verbally aggressive behaviors such as yelling at other residents. Progress notes show that on one day the provider documented that the resident had been increasingly agitated, responding to internal stimuli, refusing medications and care, and exhibiting aggressive and impulsive behavior that was considered dangerous to himself. The provider stated that the resident had failed all staff interventions to keep him safe and required a higher level of care, leading to an involuntary emergency mental health examination. The DON documented in a late entry that the resident had a burst of anger with uncontrolled behavior, including screaming, kicking the entrance door of his room and creating a hole in the wall, and kicking another wall near his TV, also creating a large hole. Law enforcement and EMS were notified, a Baker Act order was presented, and the resident was transported from the facility under this order. The DON noted that the behavior was frightening to staff and other alert residents and that the resident needed to be out of the facility for the safety of staff and residents. The clinical record did not contain documentation that a bed-hold policy was offered to the resident or his representative at the time of transfer. The hospital record shows that the resident was admitted under involuntary commitment for evaluation of mental health concerns following reported aggression at his memory care facility. On admission to the hospital, he was calm, cooperative, and oriented, with no acute distress, and denied suicidal or homicidal ideation. He was medically cleared in the ED, and a psychiatric evaluation, including telemedicine consultation, determined that he did not meet criteria for involuntary inpatient or outpatient psychiatric placement; the Baker Act and associated safety protocols were discontinued, and he was cleared for discharge from a psychiatric standpoint. Case management and social work became involved because the prior SNF refused to accept him back, and alternative placement options were explored. The DON confirmed there was no documentation that a bed hold was offered and stated that the resident’s emergency contact had declined the bed hold, and that when the resident was ready for discharge from the hospital, the facility refused to take him back because she believed he would be better off in a group home due to his age and volatile behavior. The emergency contact reported that, because the facility refused readmission, the resident was placed in another nursing home approximately 73 miles away, and she expressed a desire for him to return to the original facility. The Admissions Director stated that several days after the transfer, the hospital notified the facility that the resident was ready to return, but her regional leader instructed her not to accept the resident and not to admit him to any sister facilities. The Administrator acknowledged that a bed hold was not offered and that there was no documentation of the basis for the resident’s discharge, and stated that the regional team decided not to allow the resident to return based on information from facility staff.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors' findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied. 1. The identified resident's #2 discharge documentation was reviewed. Resident no longer resides in facility. 2. A 100% audit of all transfers/discharge forms and bed hold within the past 30 days was conducted to verify compliance with F627 requirements. Any discrepancies identified were immediately corrected, including issuance of proper notices and documentation updates. Residents under consideration for transfer/discharge will be reviewed to ensure full compliance with regulatory requirements. 3. A discharge checklist was developed to ensure all required steps are completed prior to any transfer or discharges. Education completed with all licensed nurses on discharge checklist and transfer/discharge forms and bed hold education. All planned discharges will be reviewed by IDT prior to discharge to ensure compliance. 4. Social Services Director or designee will conduct 4x/week audits of all transfers/discharges for 4 weeks, then, 3x/week x 4 weeks; then, 2x/week x 4 weeks; then, weekly x 4 weeks to ensure regulatory compliance. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly x 3 or until committee determines substantial compliance has been met.
Unsafe discharge without needed supports
Penalty
Summary
The facility failed to provide and document sufficient preparation and orientation for the discharge of a resident with significant functional and medical needs. The resident had diagnoses including acute on chronic diastolic CHF, acute pulmonary edema, obesity, COPD, chronic lower-leg ulcer, and bowel and bladder incontinence. Her admission assessment showed a BIMS score of 15, but her functional status was highly limited: bed mobility required dependent to maximal assistance, transfers were not attempted due to medical/safety concerns, walking 10 feet was not attempted, and she was always incontinent of bowel and bladder. Therapy documentation identified her as a mechanical lift resident, and progress notes described persistent debility, high fall risk, and ongoing counseling about unsafe home discharge. Despite these limitations, the resident was discharged home by stretcher with no home health services in place. The discharge summary listed home care and durable medical equipment, including a wheelchair, hospital bed, and 3-in-1 commode, but the home health agency later reported that the referral was declined because of insurance denial. Facility staff and the resident’s family reported that the resident could not walk and could not get to the bathroom by herself. The resident’s family also reported difficulty reaching social services and stated they did not know who would care for her at home. The resident was discharged without an AMA discharge notice and without notice to the Ombudsman, despite facility policy describing requirements for facility-initiated discharge and resident notification. After discharge, the resident arrived home by EMS on a stretcher and was unable to ambulate. Within less than 24 hours, she urinated and defecated on herself and was unable to change her clothing or clean her body. She was then hospitalized for CHF exacerbation and fluid overload. Interviews with facility staff showed conflicting accounts about the discharge process, the availability of home health, and whether the discharge was safe. The attending MD stated she did not recommend the resident go home and recommended long-term care, while other staff stated the resident wanted to go home and that the discharge was insurance driven.
Discharge planning did not reflect resident’s expressed home discharge preference
Penalty
Summary
The facility failed to ensure an effective discharge planning process for a resident whose condition improved and who was able to express her discharge preference. Resident #40 had diagnoses including traumatic subdural hemorrhage with loss of consciousness, Alzheimer's disease with late onset, non-Alzheimer's dementia, and traumatic brain injury. Her quarterly MDS reflected severe cognitive impairment with a BIMS score of 06, but other records and staff interviews documented that she later became able to communicate her needs and wants, participate in activities, and state that she wanted to go home with Family Member D to her home in North Carolina. The resident's care plan identified that she was resistive to care because she wanted to go home with Family Member D, and the goal focused on cooperation with care. However, the care plan did not show discharge plans once she stabilized and could make her preferences known. Facility records and interviews showed that staff were aware she repeatedly expressed a desire to discharge home with Family Member D, and multiple staff members stated she could verbalize her wishes clearly and that her cognition improved over time. The Administrator note documented that Family Member D told the facility she could provide 24/7 care, while Family Member B, listed as MPOA and responsible party, did not agree with the discharge. The record also showed confusion about the validity of the MPOA and who could make discharge decisions. The MPOA document in the chart was not signed by Resident #40, and the physician record did not show certification that she lacked competence to make health care decisions for herself. Social Services, nursing leadership, and the Administrator all acknowledged that Resident #40 expressed a desire to return home with Family Member D, but the EMR did not show action by Social Services, charge nurses, ADON, DON, or the Administrator to assist with honoring those wishes. The resident was ultimately discharged home with Family Member D after law enforcement was contacted and the physician was notified.
Failure to Allow Return After Hospital Transfer
Penalty
Summary
The facility failed to ensure resident #82 was allowed to return after an acute hospitalization. A progress note dated 3/11/26 at 8:33 PM documented that the resident was transferred to the hospital emergency room for altered mental status and increased confusion. The medical record showed no evidence that a transfer/discharge notice was provided at the time of transfer. A discharge MDS assessment showed the resident’s return to the facility was anticipated and that the discharge was unplanned, with a discharge status of Short-Term General Hospital (acute hospital, IPPS). Interviews confirmed the resident did not return to the facility after the hospital transfer. The DON stated on 5/7/26 at 9:45 AM that the decision not to allow the resident to return was financial, and also confirmed that no discharge notice was provided after transfer and that the facility did not assist in finding alternate placement. The business office manager stated on 5/7/26 at 10:54 AM that the resident was not allowed to return following the hospital transfer, although he believed the reason was insufficient staffing. The facility policy stated that residents transferred to acute care will be permitted to return upon discharge and that not permitting a resident to return following hospitalization constitutes a discharge.
Failure to Ensure Safe and Properly Planned Discharges for Two Cognitively Intact Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate, and properly planned discharges for two cognitively intact residents, resulting in noncompliance with federal requirements for transfer, discharge, and discharge planning. For the first resident, who had diagnoses including acute pulmonary embolism, acute respiratory failure, type 2 diabetes, unspecified affective disorder, and Parkinson’s disease without dyskinesia, the facility arranged same-day transportation through an outside transport company to return the resident to an assisted living facility (ALF). The Social Services Director documented that transportation was scheduled for late afternoon, but the clinical record did not contain documentation of the actual pickup date and time. The transport company later reported that the request was canceled because it did not meet their required notice time. The resident was removed from her room and placed in the activities room to wait, and staff repeatedly told her that transportation was on the way. As the day progressed, key administrative staff left the building while the resident continued to wait. The ADON reported that when he left around early evening, the resident was at the nurse’s station asking about her ride, and he told her that the ALF was coming to pick her up. He later received text messages from an RN indicating that the resident was upset and wanted to leave, followed by another message that she had left. The NHA stated that staff assumed the resident had left with her ride, even though no one actually saw her get into a vehicle. The resident reported that she had been waiting for transportation for several hours, that “the big wigs left,” and that the night nurses did not know what to do with her. She stated she eventually pushed open the door and left the facility in her wheelchair without staff awareness. She described self-propelling in the road, not knowing the route to her ALF, and being found on the side of the street by passersby who called 911. An ER physician note documented that she reported waiting all day, becoming tired of waiting, leaving, and being found on the side of the street in her wheelchair before being transported to the ER. For the second resident, who had diagnoses including degenerative disc disease, type 2 diabetes due to other mental disorder, and adjustment disorder with mixed anxiety and depressed mood, the facility discharged him to another nursing home in a different county without a documented medical reason that met regulatory criteria for transfer or discharge. A psychiatric progress note described the resident as unstable with episodes of agitation related to situational concerns about being transferred to a new nursing home. The discharge summary indicated he was being discharged to another nursing home, and a discharge order was entered without specifying the reason for transfer, level of care, or assistance needed. The written transfer and discharge notice given to the resident stated that his health had improved sufficiently so he no longer needed the services of the facility, but the resident refused to sign the form. The Social Services Assistant confirmed that the resident was not given a 30-day written notice and only received an undocumented verbal notice of about three weeks. The NHA stated that the resident was transferred because the facility was transitioning to more short-term beds, and the ADON confirmed there was no medical reason for the transfer, that the resident still needed LTC, and that the receiving facility did not provide any additional care beyond what the discharging facility could provide. The resident reported he had been told he would be evicted if he did not choose a place, that he selected one facility but was transported to another, and that after subsequent hospitalization the new facility would not readmit him, leaving him to arrange and pay for his own transportation and live in hotels.
Plan Of Correction
F627 Appropriate Discharge (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On , Resident #1 was discharged from the facility. On , Resident #2 was discharged from the facility. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken. On , NHA/Designee completed a quality review of residents discharged in the previous 30 days to ensure appropriate transportation was provided and to ensure residents/responsible parties that refuse to sign the Nursing Home Transfer Discharge Notice for non-emergent situations are provided a full 30 day notice with an appropriate reason. Any concerns noted were immediately corrected. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur. By , The NHA/Designee completed education with current social services staff and IDT team members on ensuring appropriate transportation was provided and to ensure residents/responsible parties that refuse to sign the Nursing Home Transfer Discharge Notice for non-emergent situations are provided a full 30 day notice with an appropriate reason. Any concerns noted were immediately corrected. Newly hired Social Services staff and IDT team members will be educated on ensuring appropriate transportation was provided and to ensure residents/responsible parties that refuse to sign the Nursing Home Transfer Discharge Notice for non-emergent situations are provided a full 30 day notice with an appropriate reason. Any concerns noted were immediately corrected. NHA/designee at orientation as a part of the systematic changes. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The DON/Designee will audit 5 random discharged residents to ensure appropriate transportation was provided and to ensure residents/responsible parties that refuse to sign the Nursing Home Transfer Discharge Notice for non-emergent situations are provided a full 30 day notice with an appropriate reason. Any concerns noted were immediately corrected. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met.
Discharge Process Failed to Provide Reconciled Medications and Paperwork
Penalty
Summary
The facility failed to ensure a safe discharge process for a resident with polyneuropathy, type II diabetes mellitus, a urinary tract infection, and essential hypertension. The resident’s discharge MDS showed a BIMS score of 13 out of 15, indicating intact cognition, and the discharge summary noted she had received scheduled and PRN pain medication within the last 5 days and had experienced occasional mild pain. Her care plan included monitoring a raised bruise area to the right shin and giving medication per order with monitoring for relief. At discharge, the resident was sent home at 6:56 p.m., but the discharge summary’s Current Medications section contained no entries. The discharge instruction form indicated that medication education was reviewed, prescriptions were provided, and the resident acknowledged receipt of the current reconciled medications, yet no reconciled medication list was present on the form and no scanned copy of the signed form was found in the chart. The facility’s discharge documentation also reflected items such as medications called into the pharmacy, follow-up appointments, and instructions to share the medication list with health care providers, but the record did not contain the actual reconciled medication list. The resident reported she did not receive discharge paperwork, belongings, or medications when the ride arrived, and she stated she was told she could not take her medications home because they were narcotics. She said she went the remainder of the evening and the following morning without her prescribed medications, including pain medications, and did not receive them until the next morning when the discharge planner delivered them to her home. The administrator confirmed the medications were not prepared at the time of discharge and that the facility could not produce a reconciled list of medications provided to the resident. The discharge planner and nursing staff gave differing accounts of whether discharge paperwork and medications were reviewed and provided, and the facility’s transfer and discharge policy required medication reconciliation, resident orientation for discharge, and assistance with transportation arrangements.
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