A resident with Parkinson’s disease, dementia, significant visual and hearing impairment, and multiple comorbidities, who had no prior documented aggressive behaviors, was observed by nursing staff in an aggressive incident with a roommate and was sent to the hospital for evaluation. ED and psychiatric assessments found no acute psychiatric illness and cleared the resident for SNF-level care, while ED case management notes show the facility first indicated the resident could return once a private room was available, then later stated he would not be accepted back. The resident’s spouse reported being told by hospital staff that the facility refused readmission and by the DON that there was no appeal or recourse. Facility social workers and admissions staff stated they were not involved in the decision, which the Administrator and DON acknowledged making based on the incident and hospital records, without contemporaneous physician documentation that the facility could not meet the resident’s needs. The resident ultimately did not return and was discharged home with home health services arranged by the hospital.
A resident with severe cognitive impairment, recent stroke, diabetes requiring insulin, and dependence in ADLs was discharged home after rehab despite documented need for 24‑hour care, home health, and DME. Facility staff relied on two friends as contacts, even though they repeatedly stated they could not provide 24‑hour care or assume legal/financial responsibility, and a family member listed as a contact was not included in discharge planning. The care plan lacked a person‑centered discharge component identifying responsible caregivers and coordinated services. When insurance coverage ended, the SW obtained a NOMNC by verbal consent from a friend who later reported feeling pressured and unclear about appeal options. The resident was discharged to an apartment alone, on a holiday, without confirmed 24‑hour support, with home health not yet in place and only a wheelchair delivered. In the days following discharge, home health and APS staff found the resident bedbound, soiled with incontinence, unable to answer the door or evacuate, and not consistently receiving prescribed medications, leading to hospital admission with a UTI. Surveyors determined this constituted immediate jeopardy beginning at the time of discharge.
A resident with major depressive disorder, PTSD, bipolar disorder, delusional disorders, and cataract was found in bed holding a safety razor with multiple shallow lacerations and was sent to the hospital via 911. The discharge MDS coded the transfer as an unplanned discharge with return anticipated. Hospital psychiatry later cleared the resident, and the hospital case manager contacted the facility about readmission, but the ADON reportedly stated the resident had been discharged from the facility due to a suicide attempt and would not be accepted back. The resident’s POA believed the resident would return but was later told to pick up the resident’s belongings because the resident would be discharged home, while the Ombudsman reported that the facility refused readmission and did not return her call. Facility staff, including the ADON and DON, described an internal decision that the resident would not come back for safety reasons and referenced a clinical grid and Central Admissions process, while the Administrator denied personally refusing readmission and the Medical Director stated the resident was appropriate for the facility and that the facility could not refuse to admit her under the circumstances.
A resident with dementia, severe cognitive impairment, and total ADL dependence was under a 30‑day discharge notice indicating his needs could not be met and listing his home as the discharge location, later amended to allow earlier transfer to a memory care facility. After the resident exhibited increased agitation, wandering, and unsteady gait, an RN obtained an order to send him to the ER, where he was medically cleared the same day and documented as not an imminent threat. When the hospital attempted to return him, the DON refused readmission due to safety concerns, despite the Regional Ombudsman’s communication that the facility was obligated to readmit him unless the family chose direct transfer to memory care. Email exchanges show the Administrator and DON maintained that the facility could not take him back, resulting in the resident remaining in the ER for several days before being discharged home with family and later placed in another memory care setting.
A resident with a complex abdominal surgical wound and an active wound vac order was discharged home with the expectation that home health services would provide ongoing wound care. The discharge planner sent a home health referral on the day of discharge and informed the family that services were arranged, but the agency had actually declined the case due to the resident’s geographic location and reported this to the facility after the resident left. No alternate home health provider was secured before discharge, and the resident went home without professional wound care in place, leaving family members, including an RN, to perform wound care until other outpatient services were later obtained.
A resident with a right foot fracture, cerebral palsy, and muscle weakness, who required assistance with several ADLs and was receiving PT/OT, had a documented goal to return home with home health services. Although orders and therapy discharge summaries specified discharge home with home health PT, OT, and case management, the care plan and progress notes lacked discharge planning details, and the discharge plan stated that home health would be arranged prior to discharge. The resident was discharged home and later reported that she had been told home health would be set up before leaving but did not hear from the agency until several days afterward, relying on friends for help. Interview and documentation from the home health agency and a fax confirmation showed that the facility did not send the referral until the day after discharge, resulting in a delay in initiation of home health services.
A resident with BPH, urinary obstruction requiring self-catheterization, homelessness, and cognitive impairment was discharged after skilled services ended without an effective discharge plan. The SW knew the resident was homeless and that returning to the community was not feasible, and the RR requested Medicaid assistance and long-term placement, but there was no follow-up on a Medicaid application, no confirmed housing, and no arranged home health despite therapy’s recommendation. The facility documented discharge to a homeless shelter without verifying shelter availability or obtaining an address, and discharge instructions incorrectly indicated no devices/treatments and no education or medical supplies were provided, even though the resident needed catheter supplies. The discharge was labeled AMA, an APS report was expected but never filed, and the RR reported she was not informed of appeal rights and received only medications and a medication list at discharge.
A resident with dementia and alcohol abuse, assessed as severely cognitively impaired, was transferred to the hospital for evaluation after aggressive behavior, exit seeking, and attempts to access the facility roof. On the same day as a discharge-return-anticipated assessment, the social worker informed the guardian that the resident was being issued a 30‑day discharge notice and that the facility could no longer manage his behaviors, while the administrator signed a transfer/discharge notice citing danger to others. The guardian reported being told the resident was suicidal and that the facility would not accept him back, although the resident later stated he was not suicidal and only wanted to leave. The DON and nursing staff indicated the resident became more agitated after being told he would be moved to a secured dementia unit, that he needed 1:1 supervision or secured placement, and that the facility declined his return because he would not agree to transfer to the secured unit or wear a wander guard, leading to prolonged hospitalization until alternate placement was found.
A resident was discharged and inadvertently sent home with another resident's medications after a rushed handoff during shift change. The responsible party administered the incorrect medications for several days before noticing the error, leading to an ED visit where the resident was found to be clinically stable. The error was confirmed through interviews and record review, with both nurses involved unable to explain how the wrong medications were included.
A resident with severe cognitive impairment and an indwelling urinary catheter was discharged without a completed discharge summary, missing the home health provider's information, and without documented or provided education on catheter care to the resident's representative. The representative did not receive necessary instructions or paperwork and had to seek information independently until home health services began.
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