A resident with hemiplegia, hemiparesis, schizophrenia, and bipolar disorder, who was dependent on staff for ADLs, was discharged home without a complete post-discharge plan, without confirmed DME such as a Hoyer lift, and without medications in hand. The discharge documentation failed to specify the recommended DME, lacked orders and delivery dates, omitted home health agency contact information, and left the post-discharge plan and facility contact details incomplete. After discharge, no caregivers were present at the home, the lift was not available, emergency medical services were called to assist with transfers, and the resident reported going several days without medications. Staff later acknowledged that the usual processes to ensure medications and DME were in place before discharge were not followed.
Two residents were discharged with documented needs for wound care and other post-acute services, with discharge plans and provider orders indicating they had chosen a specific home health agency for RN, MSW, and PT/OT/ST services. Despite this, the facility’s records contained no documentation that referrals were sent, received, or that the residents were accepted by the agency, and the home health provider confirmed that referrals were either missing or significantly delayed. One resident reported not being admitted to home health or seen for services until many days after discharge, and another reported receiving no home health contact and performing their own wound care. Facility social services staff and leadership acknowledged the lack of referral documentation and stated that home health services were expected to be confirmed before or at discharge, which did not occur in these cases.
Failure to develop a patient-centered discharge plan. A resident with severe cognitive impairment, dementia, a history of falls, and extensive ADL needs was told by facility staff that they needed to find another placement because the facility did not provide 1:1 care. The resident’s representative reported receiving limited help with placement, conflicting information about Medicaid coverage, and a short deadline to remove the resident or pay privately, while staff gave inconsistent accounts of the discharge plan and the resident’s payer status.
A resident with diabetes, a right foot wound, depression, and moderate cognitive impairment was discharged home without complete discharge instructions, a discharge summary, or physician orders for wound care. The discharge packet lacked documentation that blood pressure, antidepressant, and insulin medications were provided, and there was no evidence that wound care supplies or training were given to the resident or family. Facility staff, including social services, an LPN nurse manager, and the DON, acknowledged that the discharge documentation was incomplete and that required wound care orders, education, and medications were not included.
A resident with an ankle infection, mood disorder, substance abuse history, and recent NWB status was discharged to a homeless shelter without an effectively developed discharge plan or sufficient time and orientation. Care plans and managed care discharge plans identified barriers such as non‑weight‑bearing status, lack of housing, and need for placement, with LTC listed as a back‑up, but placement with DSHS was not pursued before the resident was told they had to leave. Staff reported escalating verbally aggressive behavior and suspected alcohol use, yet behavior care plans were not updated until the day police were called, and no documented behavioral health or substance abuse referrals were made. The resident stated they believed they were going to another facility or transitional housing with a bed, but was instead transported by facility van to a street‑level shelter where no bed was available, while staff and the administrator gave conflicting reasons for the discharge and acknowledged that placement options should have been explored earlier.
Surveyors found that the facility involuntarily discharged multiple LTC residents, many on Medicaid, while transitioning to a skilled-only model, without adequate documentation of a valid discharge reason, sufficient notice, or individualized discharge planning aligned with resident goals. Several residents had care plans or state case records indicating they were LTC with no discharge plan, yet were told they had to move because the facility would no longer keep LTC residents. Multiple residents and their representatives reported they were not given a real choice of receiving facility, were informed of moves on very short notice, did not pack their own belongings, and in some cases believed they were going elsewhere. Staff, including the Social Services Director and administrator, asserted that residents agreed to the moves, but their explanations were vague and conflicted with resident and family accounts. The pattern of discharges and statements from another facility’s administrator indicated that Medicaid LTC residents were being transferred out to make room for Medicare and skilled residents, implicating equal practices and discharge process requirements.
A resident with moderate cognitive impairment, impaired vision, and use of a front-wheeled walker left AMA after signing out and not returning, later reporting by phone that they were staying in a motel and did not wish to come back. Despite facility policy and staff descriptions that AMA departures should include resident education, safety checks, discharge instructions, provider and family notification, APS reporting, and EHR documentation, there were no discharge instructions or discharge summary in the EHR and no documented notifications to the emergency contact, provider, or APS for this resident.
A resident with moderately impaired cognition, poor judgment, and significant ADL dependence was discharged home against medical advice after insurance coverage ended, despite the provider not recommending discharge home alone and the resident’s son expressing concerns about unsafe home conditions, medication nonadherence, and lack of informal supports. Documentation showed the resident required maximum assist with dressing, was dependent with toileting, refused to participate in mobility and transfer training, and had poor safety awareness. Social services proceeded with planning discharge home and requested facility transportation when the resident’s ride did not arrive, and transportation staff took the resident home, while the administrator later reported being unaware that transportation had been provided.
Two residents were not allowed to return to the facility after hospitalization or therapeutic leave, despite facility policy requiring their readmission unless care needs had changed. One resident was denied return due to financial reasons after a hospital stay for respiratory distress, and another was required to be reviewed as a new admission after ER evaluation for skin breakdown, with staff unable to provide a clear reason for the denial.
A resident with diabetes, heart failure, and an indwelling urinary catheter was discharged without documented education on catheter care and without a completed home health referral. Staff interviews confirmed that neither the resident nor their caregiver received necessary training, and the home health agency had no record of a referral, resulting in the resident's rehospitalization.
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