A resident with mental health and alcohol dependence diagnoses, previously independent in ADLs and cognitively intact, was involved in an altercation that led to physical restraint by staff and transfer to jail, without documentation of a provider order for the restraint, provider notification, or post-restraint assessment. While the resident was in jail, the facility prepared a discharge summary and provider order citing non-compliance with policy and safety concerns, but failed to specify which needs could not be met, what efforts were made to meet those needs, the resident’s post-discharge residence, or follow-up appointments, and did not include clear medication discharge orders. When the resident returned from jail, the administrator and DON did not perform or document a reassessment of the resident’s needs or the facility’s ability to meet those needs, instead providing discharge paperwork, medication instructions, transportation, and limited funds, contrary to the facility’s own discharge policy requiring a comprehensive summary of status and needs at discharge.
A resident with a history of substance abuse and revoked LOA privileges left the facility with family against medical advice. Despite being informed that her LOA privileges were revoked, the resident departed, and staff processed the discharge as AMA. Attempts to obtain signatures on the AMA form from the resident and her family were unsuccessful, so staff signed with a witness. Staff interviews confirmed the discharge was due to the resident leaving without authorization, in accordance with physician orders and facility policy.
A resident with intact cognition who wished to move closer to family did not receive adequate discharge planning, as the facility failed to document or follow up on referrals and updates related to the discharge process. Staff interviews confirmed a lack of ongoing communication and follow-up, despite the facility's policy requiring continuous evaluation of discharge goals.
A resident with severe cognitive impairment and behavioral disturbances was sent to the ED after physically assaulting another resident. The facility subsequently refused re-admission and discharged the resident without providing the required notice of intent to discharge, as confirmed by the administrator. The facility's discharge policy was not provided upon request.
A resident with complex behavioral and mental health needs was transferred to another facility without being given adequate notice, the right to appeal, or the opportunity to remain during the appeal process. The transfer was conducted rapidly, with the resident not signing a discharge agreement, not being allowed to discuss the move with an advocate, and experiencing emotional distress after the move. The facility did not follow its own policies regarding resident rights and discharge procedures.
A resident with complex medical needs was discharged without a comprehensive discharge plan or confirmed home care services, resulting in worsening wounds and hospital admission. The care plan lacked discharge interventions, the social worker did not arrange services before discharge, and nursing staff assumed care was in place without verification. The facility did not follow its own discharge planning policy, and the resident was not adequately prepared for a safe transition.
A resident was discharged without a review of discharge instructions or medications with the resident or their representative, resulting in the resident being sent home with another resident's medications. Staff interviews and documentation confirmed that required procedures for medication review and discharge planning were not followed, and the discharge paperwork lacked necessary signatures.
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