A resident with CHF, COPD, morbid obesity, chronic wounds, and total bowel/bladder incontinence was discharged home by stretcher despite being a mechanical-lift resident who could not walk or toilet independently. Home health was not in place, the family reported difficulty reaching SW, and the resident was discharged without an AMA notice or Ombudsman notice. She soiled herself at home, could not clean up, and was hospitalized shortly after for CHF exacerbation and fluid overload.
A resident with dementia, TBI, and prior severe cognitive impairment later became able to clearly express that she wanted to go home with Family Member D, but the care plan did not show updated discharge goals once she stabilized. Staff across nursing, Social Services, Activities, and administration knew she repeatedly voiced this preference, yet the chart did not show action to support her discharge wishes. The record also showed confusion about an MPOA that was not signed by the resident and no physician certification that she lacked competence to make her own health care decisions.
A resident with polyneuropathy, DM2, UTI, and HTN was discharged without a reconciled med list, discharge paperwork, or her prescribed meds, including pain meds. The discharge summary had no current meds listed, the signed discharge instruction form was not found in the chart, and the resident reported she went overnight without meds until the discharge planner delivered them the next morning. Staff accounts conflicted about whether discharge instructions and meds were reviewed and provided.
A resident with COPD, respiratory failure, and severe cognitive impairment was sent to the ER after a fall and injury, and the facility treated the event as an AMA discharge when the family called 911 and the resident went to the hospital by ambulance. Facility notes stated the resident would not be accepted back, while the hospital record documented that the facility said the resident left AMA and would not return. The record also showed no documentation that the physician or designee contacted the resident or family and no Ombudsman involvement, despite the facility policy addressing AMA discharge and return procedures.
A resident with dementia, mild intellectual disability, ESRD on dialysis, depression, and behavioral issues was hospitalized for SOB and low O2 saturation. The facility’s bed-hold policy required written notice of bed-hold and return rights and mandated that residents be permitted to return after hospitalization unless formal discharge procedures were followed. The Executive Director acknowledged that no bed-hold was offered, no written notice was provided, and no 30‑day discharge notice or discharge documentation was completed. When the hospital sought to return the resident, the Executive Director stated there were no available beds and that the resident could not share a semi-private room due to a prior incident of hitting a roommate, despite census records showing an available female bed. The PASRR supervisor and the resident’s guardian reported multiple unanswered attempts to coordinate the resident’s return and stated the Executive Director made it clear he did not want the resident back. The resident’s belongings were packed by staff and handed to the guardian at the entrance, with missing items not documented through a grievance process. These actions and omissions resulted in the resident not being readmitted from the hospital in accordance with the facility’s own bed-hold and return policy.
Discharge planning was not developed or implemented for four residents. One resident with bipolar disorder and dementia had an attempted transfer, but the family said care plan meetings did not address discharge goals and requested records were not provided to the receiving facility. Three other residents, including cognitively intact residents with psychiatric, cardiac, mobility, and other diagnoses, had care plan conferences and care plans that did not include discharge planning; the DON confirmed no discharge care plans were in place, and the LSW said discharge goals were not routinely reviewed.
A resident with a history of stroke, hemiplegia, dementia, and psychiatric conditions was admitted, then sent to the hospital the next day for evaluation of possible aspiration related to a G-tube. Documentation showed an unplanned discharge to a short-term hospital, and the resident was not allowed to return. Interviews with the DON, ADON, BOM, and Marketer/Admissions revealed the resident had been clinically but not financially approved, was admitted by confusion while management was absent, and was not funded or fully identified. Staff acknowledged that transportation had been arranged for another individual and that, once the error was recognized, the resident was not readmitted after hospitalization, contrary to the facility’s written discharge planning policy regarding residents returning from the hospital.
A resident with ESRD on dialysis, diabetes with foot ulcers, heart failure, and depression, who was cognitively intact and independent in self-care, was issued a 30‑day discharge notice related to non‑payment and behavioral concerns. The notice, however, specified a discharge date only a few days after issuance rather than 30 days later. Social services documented active planning for the resident’s move to an apartment and coordination with community providers, but the resident was hospitalized before the 30‑day period elapsed. When the hospital prepared to discharge him back, facility leadership informed the Ombudsman that the owner did not want to take him back and did not want to honor the 30‑day notice, and the resident was not readmitted during the 30‑day window. Surveyors found this constituted a failure to provide a proper 30‑day discharge date and a failure to readmit the resident from the hospital within that 30‑day period, violating discharge requirements.
A resident with prostate CA, a documented cognitive communication deficit, and partial visual impairment was admitted for rehab with a family member designated as responsible party, who signed all admission documents. Despite this, the administrator later called the resident alone into the office, presented a NOMNC, and had the resident sign it without notifying or involving the designated representative, even though the resident reported not understanding what he was signing and relying on family to handle his paperwork. The responsible party stated she was not informed of the discharge notice and only learned of it when the resident called saying he had signed papers and was being put out, while facility records and staff interviews showed the EHR listed a family responsible party and that prior instructions at admission were to have the family sign because the resident probably would not understand the documents.
A resident with severe cognitive impairment, schizophrenia, and other psychiatric and neurological conditions, who was on multiple psychotropic meds and receiving psych and psych NP services, was issued a 30‑day discharge notice for behavioral reasons without clear clinical documentation that his needs could not be met in the facility or that he posed an unmanageable danger. Facility records showed intermittent behaviors, including medication refusals, yelling, room entry, and two physical incidents, with 1:1 monitoring and med adjustments but no documented evaluation of intervention effectiveness and no state incident report for a resident‑to‑resident altercation. The facility obtained an OPC to send the resident to an inpatient behavioral hospital and, after his psychiatric stabilization, refused readmission while discharge planning and communication with the hospital, a proposed group home, and the resident’s RP were inconsistent and conflicting, resulting in an unsafe and poorly coordinated transfer and discharge process.
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