The facility failed to implement its transfer/discharge policy by not providing required orientation and caregiver training to a responsible party before a high fall-risk resident with HTN, DM, CHF, moderate cognitive impairment, and substantial/maximal ADL assistance needs was discharged home. OT and PT notes documented falls, poor safety awareness, and the need for precautions, with therapy staff stating the resident required minimal to moderate assistance and cueing for ambulation and transfers. Both therapy staff and the ADON confirmed that no caregiver training or orientation was provided or documented for the responsible party, despite policy requiring resident/representative notification, orientation, and documentation for discharges.
A resident with a right lower leg amputation, who primarily used a wheelchair and required at least supervision or touching assist to ambulate short distances with a FWW, was discharged to an independent living facility (ILF) that only accepted fully independent individuals and did not accommodate wheelchair-level care. Facility social services staff informed the ILF that the resident could walk independently up to 150 feet with a walker and did not need a wheelchair, despite ADL, weekly summary, PT, and OT documentation indicating wheelchair-level mobility and assisted ambulation only with therapy. At discharge, ILF staff refused to accept the resident upon realizing he was non-ambulatory, and the resident reported having previously told the social worker he was not ready to leave because he could not walk, resulting in significant distress when he was turned away.
A resident with significant mobility limitations and fear of falling required substantial assistance for transfers and could not ambulate safely. Despite documented concerns about the primary caregiver’s financial pressure, verbal abuse, and threats, and repeated cancellations or refusals of car-transfer training, the IDT proceeded toward discharge at the caregiver’s insistence without a complete, coordinated discharge plan. On the day of discharge, the caregiver rushed the process, did not wait for staff to complete discharge instructions or assist with the transfer, and attempted to move the resident from wheelchair to car without having accepted training, resulting in a fall in the parking lot. Staff, including the DON and DOR, later acknowledged that caregiver training had not been completed and that the discharge plan did not clearly define transport responsibilities.
A resident with a history of lower extremity fracture and osteomyelitis, who had become non‑weight bearing and only able to perform minimal side stepping with moderate assistance, was discharged home when insurance benefits were exhausted. The care plan called for discharge home with family, and case management informed a family member of the discharge date and that 24/7 care would be needed, but did not clearly communicate the resident’s current ADL and ambulation limitations or document any caregiver training or assessment of the family’s ability to provide required care. Staff interviews confirmed that the resident was not ambulating, required assistance for transfers, and that the family was not prepared for the level of care needed, contrary to facility policy requiring evaluation of caregiver availability, capacity, and capability in the post‑discharge plan.
A resident with heart failure was discharged home with a documented post-discharge PCP appointment, but the appointment was not explained to the resident or family. The case manager scheduled the PCP visit but did not review it with the resident, believing this was the responsibility of the LPN completing the discharge. The LPN who discharged the resident did not discuss the appointment, believing it was the case manager’s responsibility. The DON later stated both the case manager and LPN should have communicated the scheduled PCP visit, and the facility’s transfer/discharge policy lacked guidance on discharge planning and communication of the discharge plan.
A resident with a history of stroke sequelae and anxiety, and mild memory impairment, was transferred by non-emergent transport to a hospital ED for reported behavioral symptoms without accompanying paperwork, prior physician or family notification, or a documented assessment supporting the need for transfer. Hospital case management documented that the resident was calm, cooperative, and agreeable to return, yet the facility’s Admission Coordinator repeatedly refused readmission, citing rooming concerns, despite multiple open beds. The facility completed a discharge notice indicating the resident was not expected to return, but the notice and required information on appeal rights and bed-hold policy were not provided at the time of transfer, and the LTC Ombudsman was notified only later. The DON and ADON confirmed there was no documentation of a bed-hold offer, no transfer packet, no required transfer/discharge notices, and no assessment of the resident’s status and needs at the time of proposed return, contrary to the facility’s own transfer/discharge policy.
Failure to Permit Return After Hospitalization: A resident with severe cognitive impairment and multiple neurologic and psychiatric diagnoses was sent to the hospital for a change in condition and later had new behaviors and quetiapine added. The ADC, DON, and Administrator decided the facility could not accommodate the resident because of the new medications and behaviors, declined the resident in the referral system, and did not permit the resident to return despite available beds.
A resident with paraplegia was transferred to a GACH and, shortly after admission, was documented as calm, cooperative, medically cleared to return, and expressing a desire to go back to the original SNF, where an active bed-hold was in place. Despite this, the facility declined to readmit the resident when the hospital attempted to discharge him back, and instead the resident was later discharged to another SNF. In interviews, the AD and Administrator confirmed the decision not to readmit, which conflicted with the facility’s bed-hold and return policy requiring residents seeking to return within the bed-hold period to be allowed back to their previous room and evaluated based on their current condition.
A resident with dementia, behavioral disturbance, chronic pain, encephalopathy, anxiety, insomnia, cerebral palsy, and recurrent depressive disorder was hospitalized for uncontrolled pain and a change in mental status and later deemed stable for transfer back to a SNF. Despite repeated requests from the family and hospital case management, the facility refused readmission, citing unspecified needs and behaviors and inquiring if the family could pay for a 24-hour private sitter, without clearly identifying which care needs could not be met or documenting a change in condition requiring a different level of care. The DON reported that residents are permitted to return after hospitalization, while the Administrator stated the facility could not manage the resident’s care, referenced worsening behaviors, and acknowledged that the decision not to readmit was made by non-clinical corporate staff, contrary to the facility’s bed-hold and return policy requiring evaluation based on the resident’s current condition.
A resident with paraplegia and COPD, who was cognitively intact, was transferred to an acute care hospital for respiratory issues and confusion, but the facility failed to follow its own policies for transfer and discharge. The resident did not receive or sign a 7‑day bed-hold form, there was no dual-nurse verification of verbal consent, and neither the resident nor family were informed of bed-hold provisions or the right to appeal the discharge. No discharge physician order was obtained, and there was no documented discussion with the resident or representative about discharge. Additionally, no change in condition assessment was completed, and the resident’s care plan was not updated to reflect the hospital transfer and change in health status.
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