A resident with multiple cardiac and musculoskeletal conditions, recently post-CABG and receiving subacute rehab, was discharged home with documented plans and NP recommendations for continued home health PT, OT, nursing, and a bath aide. Social services documented that in-home services would be arranged through a local home health agency, but the discharge instructions given to the resident stated that no services were contacted and did not list any home health provider. After discharge, the resident and family waited for home health that never arrived and later learned from the home health intake coordinator that no referral had been received from the facility; services were only started after the family contacted the agency and orders were obtained from the physician’s office. This sequence of events shows the facility failed to implement the planned home health referral and did not ensure that post-discharge services were actually arranged.
A resident who engaged in self-harm was sent to a hospital behavioral unit, and on the same day the facility issued an involuntary discharge notice stating the resident’s needs and welfare could not be met and that safety was endangered. The hospital psychiatric NP later documented that the resident was A&O x4, denied SI/HI, expressed remorse, was on low suicide precautions, and only required routine psychiatric follow-up and medication monitoring, and reported that the facility declined to readmit the resident despite her being cleared for discharge. The Administrator and a general NP expressed concerns about supervision and lack of onsite psychiatry, but the facility did not perform or document any clinical or psychosocial assessment of the resident between transfer and the proposed return, nor did it document specific needs that could not be met, contrary to its own involuntary discharge policy.
A resident with a history of stroke, aphasia, hemiplegia, seizure disorder, and significant communication and cognitive impairments, whose preferred language was Vietnamese and who required an interpreter, was transferred from the unit to a local county hospital ED without written notice of transfer/discharge to the resident or the state guardian. Staff had long known the resident had no insurance, no family, and a state guardian, and that prior placement attempts had failed due to financial and identity issues. As the unit prepared to close, staff contacted a hospital transfer center, which declined admission for lack of acute need, yet the facility still arranged a private ambulance transfer to the ED based on reported verbal direction from county officials, without documented discharge planning, referrals, a discharge care plan, or a written notice specifying the reason, effective date, and destination of the transfer.
A resident was involuntarily discharged for being a threat to another resident’s personal safety, but the EMR lacked a physician note documenting the basis for the discharge, the specific needs that could not be met in the facility, the attempts made by the facility to meet those needs, and the services available at the receiving facility. The Administrator and DON/Regional Consultant confirmed that no such physician documentation existed in the record, and the Administrator acknowledged not being aware of all requirements for an involuntary discharge.
A resident with ESRD dependent on hemodialysis was discharged home without a confirmed dialysis chair date and time, despite a care plan specifying scheduled dialysis and a facility policy requiring Social Services to arrange outside services and equipment before discharge. Documentation showed that at the time of discharge the dialysis time was still pending, yet the resident’s family proceeded with discharge and leadership was notified. The family reported they were told they would be called with the dialysis schedule but never received a call, and the resident subsequently required dialysis at a local hospital ER. The DON later stated that Social Services were expected to arrange all home health services, including confirmed dialysis, and to notify the physician if a resident insisted on leaving.
A resident was sent out for an appointment without the required transfer documentation, including a face sheet, physician orders, and MAR, contrary to facility policy. The DON stated that staff are informed of appointments in advance and are expected to prepare and send this paperwork with the transporter. The resident’s night nurse reported she was unaware of the appointment and, although she had printed the necessary documents, did not send them because she could not access the computer room to retrieve them.
The facility failed to properly justify and document involuntary discharges for two residents. One resident with depression, no documented history of aggressive behaviors, and a recent episode of self-harm after a family death was petitioned for involuntary discharge and not allowed to return, while the notice cited danger to others but the record lacked physician documentation or evidence of behaviors endangering other residents. Another resident with paranoid schizophrenia and repeated smoking in non-designated areas, profanity, and aggression was issued an involuntary discharge notice stating that the resident’s needs could not be met, yet the record contained no physician documentation explaining the discharge, what needs could not be met, or what services had been attempted beyond a smoking behavior contract.
A cognitively intact paraplegic resident with multiple chronic conditions was issued an emergency involuntary discharge, and the facility independently selected an accepting out-of-state facility without allowing the resident to participate in choosing the destination. The resident, who wished to return to a different state where he had previously lived, reported that he was not asked about his preferences or offered options consistent with his wishes. The Administrator, SSD, and Director of Admissions acknowledged that referrals were sent and an accepting facility was secured before informing the resident, and that the resident was not permitted to suggest facilities, despite policy and resident-rights materials stating that residents have the right to participate in their own care planning.
A resident with vascular dementia, who was cognitively intact and previously described as calm and cooperative, was sent to the hospital for agitation and was not allowed to return based on behavior concerns decided by the Administrator and DON. The facility could not provide a physician assessment or psychiatric reassessment supporting that the resident could not be safely cared for, and the primary physician reported no evaluation had occurred. There was no written discharge notice, no discharge planning documentation, and no evidence the resident or representative was informed of appeal rights, despite facility policies requiring adherence to bed hold/readmission rules and proper discharge planning once a physician discharge order is obtained.
A resident with cognitive impairment and complex medical needs was transferred to another facility following an altercation, without proper involuntary discharge paperwork or advance written notice. The resident and her family were not informed of their rights, and staff were unaware of the discharge until it was occurring. The ombudsman intervened, and an administrative law judge ordered the resident's return, highlighting the facility's failure to follow required discharge procedures.
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