A resident with paraplegia, multiple chronic conditions, colostomy, urostomy, indwelling catheter, and multiple pressure and diabetic ulcers was discharged home despite being totally or largely dependent for ADLs, transfers, and complex wound and ostomy care. Care plans and MDS data showed the resident required extensive assistance, and MAR/TAR review revealed some wound and skin treatments were undocumented on at least one day before discharge. The record contained no documentation that the resident was educated on ostomy management or how his ADL needs would be met at home. Home health was arranged only for intermittent skilled nursing and therapy, without a home health aide, and the resident’s Medicaid waiver services had been lost, leaving his blind, developmentally disabled spouse as the primary caregiver. Staff interviews confirmed the resident had not been taught to manage his own care and relied on staff for bathing, transfers, and ostomy and wound care, leading surveyors to determine the facility failed to ensure a safe discharge.
Surveyors found that the facility failed to ensure a comprehensive discharge process for a resident with multiple complex conditions and an active plan to return to the community, as the care plan was not updated to reflect discharge planning, the discharge summary lacked a reconciled medication list, and there was no documented evidence that prescriptions were accurately provided or transmitted at discharge. In addition, another cognitively intact resident who was transferred to the hospital and later readmitted had no documentation that they or their representative received a required bed-hold notice or were offered the option to hold the bed, contrary to facility policy.
The facility failed to provide required bed-hold notifications to two long-term residents and/or their representatives when the residents were transferred to the hospital after changes in condition. One resident with atherosclerotic heart disease, post-laminectomy syndrome, and cognitive impairment, and another with heart failure, pulmonary fibrosis, dysphagia, and memory problems, were both dependent on staff for ADLs and had designated representatives or POAs. For multiple hospital transfers, their medical records contained no documentation of bed-hold notices detailing remaining covered bed-hold days, despite the Admissions Director’s statement that such notices are given and filed, and despite a facility policy requiring a bed-hold letter and policy at admission and with each discharge or transfer.
A resident discharged with multiple medical conditions, including dysphagia and hypertension, did not have a signed discharge summary verifying receipt of wound care instructions, even though the form required a resident or responsible party signature. Record review showed the resident was cognitively intact and required set-up to moderate assistance with ADLs at discharge, yet no signature was present. An RN confirmed she did not obtain the resident’s signature, and leadership later identified that nurses were not consistently obtaining required signatures on discharge summaries, resulting in a cited deficiency related to the discharge process.
A resident with multiple medical conditions, moderately impaired cognition, and a court-appointed guardian was discharged home without guardian approval and with HHC arranged only on the day of discharge. Documentation showed the resident required assistance with ADLs and had functional decision-making impairments, yet social services recorded that the resident insisted on going home, refused LTC placement, and arranged transportation with a family member. Discharge notes indicated instructions and medications were provided, but interviews confirmed that the guardian did not authorize the discharge and that the timing of the HHC referral did not follow the facility’s usual practice, resulting in a failure to ensure a safe and orderly discharge as required by facility policy.
A resident who was cognitively intact and required supervision with ADLs was discharged AMA at the request of a representative, and an LPN mistakenly sent home another resident’s medications and discharge instructions. The error was discovered at shift change when staff could not locate the other resident’s medications, and the discharged resident’s representative later reported the issue to police and returned the incorrect medications and paperwork. The Administrator and DON stated staff realized the error a few hours after discharge, and facility policy required a discharge planning process to ensure a safe transition that met the resident’s needs.
A resident with dementia and multiple comorbidities, who remained largely independent in ADLs, and the resident’s daughter/POA repeatedly requested transfer to another facility with a memory care unit. An LPN documented the resident believed she was supposed to move but there were no discharge or transfer orders, leading to resident agitation. Social services and admissions staff documented that referrals would be sent to several named facilities, but email correspondence and staff interviews showed miscommunication over who was responsible for sending the referrals and confirmed that only one referral was actually sent. This failure to timely and consistently act on the resident and family’s discharge and transfer request did not align with the facility’s discharge planning policy.
A resident with chronic pain, ESRD on hemodialysis, heart disease, and mildly impaired cognition was found unresponsive, received CPR, and was transferred to a hospital where death was later confirmed. Although a nurse’s progress note described the event and attempts to phone family, the facility did not complete a discharge/transfer summary, did not document written notice of the transfer/discharge to the resident’s representative, and did not document that required discharge information was communicated to the receiving hospital. The SW and ADON both confirmed the absence of a discharge summary and other required transfer documentation in the medical record, resulting in a deficiency related to discharge documentation and communication requirements.
A resident with severe cognitive impairment and multiple complex medical conditions was transferred twice to the hospital, but the facility failed to provide required bed-hold notices and written transfer/discharge notices to the resident or representative at the time of either transfer. Documentation showed only clinical information sent to the hospital and a telephone Notice of Medicare Non-Coverage, with no evidence that bed-hold rights or written discharge notices were issued, even after the facility decided the resident would not be allowed to return. The Administrator and Regional Business Office Manager stated that bed-hold notices were only given to Medicaid residents, and the DON was unable to explain the bed-hold process, despite facility policy requiring written bed-hold information and acknowledgment for all residents regardless of payor source.
A resident with multiple complex medical conditions and cognitive impairment was discharged home with family present, but the LPN responsible did not complete the nursing section of the discharge paperwork. There was no documented review of discharge medications and no indication that prescriptions or a three-day supply of medications were offered, despite facility policy requiring a complete discharge summary and medication reconciliation. The Ombudsman and DON both confirmed the discharge documentation was incomplete and that medications were not reviewed or offered.
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