A resident with schizoaffective disorder, dementia with behavioral disturbance, and PTSD had a history of verbal and physical aggression, exit-seeking, and medication refusal, culminating in an incident where the resident struck a nurse and was sent to an acute psychiatric hospital. Facility documentation showed no 30‑day transfer/discharge notice to the resident’s representative, no documentation of appeal rights or bed-hold policy, and a discharge MDS that characterized the hospitalization as an unplanned discharge with return anticipated. After transfer, the psychiatric hospital Social Worker repeatedly attempted to coordinate the resident’s return, but the DON was often unavailable, the receptionist stated the resident was not allowed back, and facility staff gave inconsistent, undocumented explanations that the resident would not be re-admitted or had been discharged to another SNF, despite the hospital and the representative reporting no such acceptance. The facility’s actions and omissions conflicted with its own transfer/discharge policy requiring 30‑day notice for non-emergency discharges, continuity of care planning, and provision of bed-hold information.
A resident with severe cognitive impairment, multiple medical conditions, and significant care needs was discharged home alone without verified support or caregiver involvement. The facility did not assess the resident's ability to manage her prescribed diet, medications, or activities of daily living, nor did it provide discharge education to a responsible caregiver. The facility relied on unverified statements about a support network and did not assist with Medicaid applications or power of attorney, resulting in the resident being discharged to an unsafe environment.
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 process did not meet the individual's needs or preferences.
A resident with multiple neurological diagnoses was discharged without complete documentation, as required by facility policy. The discharge form lacked a selected reason for transfer, and the physician's order did not provide sufficient detail regarding the discharge. Staff interviews confirmed that required documentation fields were left blank or incomplete.
A resident with multiple chronic conditions and a history of verbal aggression was discharged after a verbal altercation and police involvement, but the facility failed to provide supporting documentation or rationale for the discharge, did not address the resident's needs or preferences, and did not offer the resident the opportunity to return after hospital observation, resulting in a deficiency related to safe and appropriate discharge procedures.
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