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.
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 multiple mental health diagnoses was transferred to a sister facility over 100 miles away primarily for more lenient smoking times, without documented interdisciplinary discharge planning, resident consent, or a written physician order. Staff interviews gave conflicting reasons for the move, and social services reported no involvement despite facility policy requiring interdisciplinary planning and review with the resident. The resident reported being told abruptly to pack and leave, stated he never signed discharge forms, and said his family and support system remained in his original city, contrary to statements that the transfer would place him closer to family. Records showed no smoking-related care plan, no documented noncompliance with the smoking policy, no exploration of closer placement options, and no evidence that the resident’s preferences and psychosocial needs were considered in the discharge decision.
A resident with a history of traumatic brain injury, mood and anxiety disorders, and intact cognition on recent MDS had a care plan goal to remain in LTC at the facility. After an acute behavioral episode involving yelling and property damage, the resident was Baker Acted and transferred to the hospital. The facility’s policy required that residents sent emergently to acute care be permitted to return unless specific discharge criteria were met, and that a bed-hold policy be offered; however, there was no documentation that a bed hold was offered or that regulatory criteria for facility-initiated discharge were met. Hospital records showed the resident was calm, cooperative, and did not meet criteria for involuntary psychiatric placement, but the facility, following regional direction, refused to readmit the resident, leading to placement in another nursing home far from the resident’s family.
Two residents with intact cognition experienced unsafe and inappropriate discharges when the facility failed to confirm and document transportation, ensure supervision until departure, provide proper notice, and accurately document reasons and destinations for transfer. One resident with multiple serious medical conditions waited for hours for a ride that had been canceled by the transport company, then left the building in a wheelchair without staff awareness and was later found on the roadside and taken to the ER by EMS before being sent to an ALF. Another resident with diabetes, spinal disc degeneration, insomnia, and depressive disorders was told he had to choose a new facility or be evicted, was not given a 30‑day written notice, refused to sign the transfer form, and was discharged without a documented medical reason to a different nursing home than the one he reported choosing, later incurring personal costs and housing instability after the receiving facility would not readmit him post‑hospitalization.
A resident with a history of stroke, Afib, cognitive communication deficit, and type 2 DM was denied readmission after a hospital stay, despite prior indication from the facility that her return was expected and no documented clinical reason preventing it. The family reported the facility refused to take her back at the last moment, causing an extra hospital day and anxiety while they urgently sought another SNF. The ADA told the hospital CM the facility could not accommodate the resident’s diet and later referenced vague clinical limitations that could not be defined, while the DON stated the denial was marked as a clinical services issue because the family strongly advocated for the resident’s preferences regarding daily routine and therapy. The facility physician stated there was no medical or dietary reason the resident could not be readmitted, and the resident’s orders reflected a regular diet with vegetarian options, consistent with the facility assessment and policies that state it can accommodate individualized, cultural, and religious dietary needs.
A resident with multiple medical conditions, including post-amputation orthopedic aftercare, osteomyelitis, COPD, and muscle weakness, was discharged home with a PT note indicating home health was recommended, but without documentation that these services were arranged or that required discharge planning steps were completed. The resident filed an appeal with DCF, asserting they were being erroneously discharged, yet the EMR contained no documentation of the appeal, no AHCA discharge/transfer form, and no discharge summary. The SSD confirmed the absence of these records, and the NHA acknowledged that Social Services should document discharge assessments and that residents who appeal should not be discharged until an appeal decision is made, but stated that coverage gaps in Social Services led to discharge processes not being done correctly.
A resident with multiple complex conditions, including a stage 3 pressure injury requiring daily wound care, was discharged home without a documented discharge plan, without confirmation of home health services, and without needed supplies. Progress notes and the care plan lacked evidence of discharge planning discussions with the resident or representative, and there was no nursing documentation of discharge education or supplies provided. Social services documented that home health was expected, but later learned after discharge that the initial home health agency had not agreed to accept the resident, and the resident’s family reported that no home health visit occurred and no supplies were sent home, contrary to facility discharge planning policy.
A resident was not adequately prepared for a safe transfer or discharge, and the facility did not ensure that the process met the resident's needs and preferences, resulting in a deficiency related to proper transition planning.
A resident was not adequately prepared for a safe transfer or discharge, and the facility did not ensure that the process met the resident's needs and preferences, resulting in a deficiency in care planning and transition.
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