Inadequate Discharge Planning and Coordination
Summary
The facility failed to ensure adequate preparation and coordination of services prior to the discharge of a resident to their home. The resident, who was cognitively intact, required substantial assistance with activities of daily living and had multiple complex medical conditions, including diabetic foot ulcers and a right below-knee amputation. The discharge plan was initiated with an undetermined plan to return home or remain in long-term care. However, upon discharge, the facility did not provide necessary wound care instructions or supplies, nor did they notify the home health agency of the resident's discharge. The physician's discharge orders included specific wound care treatments, such as negative pressure wound therapy and dressing changes, but these were not communicated to the home health agency. Consequently, the resident was not contacted for an initial visit by the home health agency until several days after discharge, and the required physician evaluation by the community primary care physician was delayed. The Director of Nursing confirmed that no education or supplies were provided to the resident or their representative for wound dressing changes at the time of discharge, and there was no evidence of notification to the home health agency.
Penalty
A resident with multiple complex medical conditions was subject to an emergency discharge after being accused by two other residents of possessing a firearm, though no weapon was found. The resident was denied re-entry, police were called, and the resident was discharged without a safe destination or arrangements for ongoing wound care. The resident's belongings were placed by the dumpster, and the individual left the property in a wheelchair without transportation or a coat, later spending two days in a car before being hospitalized.
A resident with multiple medical conditions and significant care needs was discharged without home health services being properly arranged. Although staff believed arrangements had been made, the selected home health agency did not serve the resident, and no follow-up calls were documented to verify post-discharge care. This resulted in the resident not receiving necessary home health support after leaving the facility.
A resident with a history of bipolar disorder and schizophrenia was discharged from a facility without a 30-day notice and was initially sent to a homeless shelter, which refused him due to past behaviors. The facility did not attempt to find alternative placement and relied on a caseworker's plan, leading to the resident being taken to multiple hospitals before being admitted. The facility's policy on discharge was not followed.
The facility failed to ensure a safe and orderly discharge for two residents, resulting in deficiencies in discharge planning and coordination of home health care services. One resident was discharged without timely coordination of home health care services, leading to a delay in receiving necessary support and equipment. Another resident experienced a delay in the coordination of home health care services and equipment due to a delay in receiving therapy notes and the unavailability of a Certified Nurse Practitioner to sign the discharge paperwork.
A resident with cognitive deficits and multiple medical conditions was discharged to the ER for a psychiatric evaluation without a proper care plan or necessary paperwork. The resident was transported by a CNA/Van Driver instead of a nonemergent transport service, and was left at the ER without documentation. Communication issues between the facility staff and the resident's daughter contributed to the unsafe discharge process.
A resident with multiple medical conditions was discharged from an LTC facility without the legal guardian's consent. The facility staff did not have the guardianship paperwork in the medical record, leading to the oversight. The resident's mother initiated the discharge, and the guardian was informed only after the discharge occurred. The facility's policy requiring a 30-day notice for discharge was not followed.
Failure to Provide Safe and Orderly Discharge for Resident
Penalty
Summary
The facility failed to provide a safe and orderly discharge for a resident who was subject to an emergency discharge following allegations from two other residents that the individual possessed a firearm and had made threats. The resident, who had diagnoses including unspecified paraplegia, a stage III pressure ulcer, chronic pain syndrome, malnutrition, morbid obesity, bipolar disorder, and neuromuscular bladder dysfunction, left the facility without signing out and was later refused re-entry. Despite multiple attempts by the social worker to secure alternative placement and community resources, no emergency housing or LTC facility would accept the resident, and the resident was unavailable to participate in discharge planning. When the resident returned to the facility, staff, following instructions from administration and police, did not allow entry and called law enforcement. Police searched the resident and found no weapon. The resident was given discharge paperwork, a face sheet, a medication list, and routine medications (excluding narcotics), but was not provided with a safe discharge destination or arrangements for ongoing wound care. The resident's belongings were packed in trash bags and placed by the dumpster, and the resident left the property in a wheelchair without a coat or transportation, ultimately spending two days in a car before being hospitalized for a stomach infection. Interviews with staff, the Ombudsman, and police confirmed that the resident was discharged without a safe destination, and that the facility's discharge notice inaccurately listed a destination. The resident did not take any belongings with him, and staff were unclear about his whereabouts after leaving. The facility's own policy required advance preparation for discharge, including assistance with transportation and ensuring a safe discharge location, but these steps were not followed in this case.
Failure to Arrange Home Health Services Prior to Discharge
Penalty
Summary
The facility failed to ensure that home health services were arranged prior to the discharge of a resident with significant medical needs. The resident, who had diagnoses including cerebral infarction, hemiplegia, hemiparesis, vascular dementia, dysphagia, impulse disorder, major depression, and intermittent explosive disorder, required assistance with most activities of daily living and was incontinent. Although the social worker faxed information to a home health agency before discharge, the agency later confirmed they did not have the resident as a client and did not serve individuals under the age of 60. The resident reported not receiving any home health services after discharge. Interviews with facility staff, including the Social Service Designee, Administrator, and DON, revealed they believed home health services had been arranged, but were unaware that the resident was not receiving them. Review of facility policy indicated that discharge planning should include arranging for home health and follow-up calls post-discharge, but there was no documented evidence that follow-up calls were made to the resident after discharge. This deficiency was identified during a complaint investigation and affected one resident out of three records reviewed.
Failure to Ensure Safe and Orderly Discharge
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for a resident, identified as Resident #90, who was admitted for surgical after-care following knee surgery and had a history of bipolar disorder and schizophrenia. The resident was initially discharged to a homeless shelter at the request of a caseworker, but the shelter refused to accept him due to his past behaviors, including setting fires. Consequently, the resident was returned to the facility and later discharged again to a hospital, which had previously discharged him, without a confirmed placement. The facility's management was unaware of the resident's violent incidents during his hospital stay prior to admission, as these were not communicated in the hospital notes shared with the facility. Despite the resident not exhibiting violent behaviors while at the facility, the caseworker insisted on discharging him due to his history. The facility did not provide a 30-day discharge notice or attempt to find alternative placement, relying instead on the caseworker's plan, which ultimately led to the resident being taken to multiple hospitals before being admitted. Interviews with facility staff and the caseworker manager revealed that the resident was improperly placed in the facility and that the caseworker should not have taken responsibility for the resident's discharge. The facility's policy on notice of transfer and discharge was not followed, as the resident was not given a 30-day notice, and the discharge was not conducted in a safe and orderly manner, as required by the policy.
Deficiencies in Discharge Planning and Coordination of Home Health Care Services
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for two residents, resulting in deficiencies in discharge planning and coordination of home health care services. Former Resident #8 was discharged to home without timely coordination of home health care services. Although the resident's daughter had informed the Social Service Designee (SSD) of the need for home health care and the chosen companies, the referral was not sent until after the resident's discharge. This delay, compounded by the holiday period, resulted in the home health care company not contacting the resident until several days after discharge, leaving the resident without necessary support and equipment. Similarly, Former Resident #9 experienced a delay in the coordination of home health care services and equipment. The SSD did not complete the referral for home health care services until two days after the resident's discharge, due to a delay in receiving therapy notes and the unavailability of a Certified Nurse Practitioner to sign the discharge paperwork. This resulted in a delay in the resident receiving a wheeled walker and other necessary care. The facility's policy on discharge planning was not followed, leading to these deficiencies in ensuring residents were prepared for a safe discharge.
Failure to Ensure Safe and Orderly Discharge of Resident
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for a resident, identified as Resident #73, who was discharged to the emergency room (ER) for a psychiatric evaluation. The resident had a history of multiple medical conditions, including a urinary tract infection, altered mental status, and cognitive deficits. Upon admission, the resident exhibited aggressive behavior, was exit-seeking, and was considered a fall risk while on anticoagulation therapy. The Director of Nursing (DON) decided to send the resident to the ER for evaluation due to the risk of harm to herself and others. The discharge process was not handled appropriately, as there was no 48-hour care plan initiated for the resident. The facility's staff, including RN #805 and LPN #807, failed to ensure that the necessary discharge paperwork was printed and sent with the resident. Additionally, the resident was transported to the ER by a CNA/Van Driver instead of a nonemergent transport service, as the latter would have required a long wait. The CNA/Van Driver left the resident at the ER with a security guard without any paperwork, and the resident's daughter, who was supposed to meet them at the ER, was not present at the time of arrival. Interviews with the resident's daughter and facility staff revealed discrepancies in communication regarding the discharge process. The daughter claimed she informed the facility that she needed to stop at home before going to the hospital, but this was not acknowledged by the staff. The CNA/Van Driver and RN #805 both stated that the daughter was aware of the plan to send the resident to the ER, but there was no clear communication or documentation to ensure a safe and orderly discharge. This deficiency was investigated under Complaint Number OH00160463.
Failure to Notify Guardian of Resident Discharge
Penalty
Summary
The facility failed to ensure that the legal guardian of a resident was informed and gave consent for the resident's discharge. The resident, who had multiple medical diagnoses including pulmonary edema, Asperger's syndrome, diabetes, and dependence on renal dialysis, was discharged from the facility without the guardian's approval. The resident had moderate impairment in decision-making and required assistance with daily activities. The discharge was unplanned and initiated by the resident's mother, who was not the legal guardian. The facility's staff, including an LPN and the Social Service Director, did not have the legal guardianship paperwork in the resident's medical record, which led to the oversight. The LPN notified the physician of the resident's request to leave but did not contact the guardian due to the absence of guardianship documentation in the chart. The guardian was only informed of the discharge after it had occurred, during an unannounced visit to the facility. The facility's policy required a 30-day notice for discharge unless it was necessary for the resident's welfare, which was not adhered to in this case. The guardian expressed disagreement with the discharge and stated that the facility did not prepare the resident for a safe discharge. The resident was later placed in another facility and passed away due to complications from COVID-19 related pneumonia.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
Self-audit
Pick a level of detail and, optionally, what to focus on — then generate a survey-ready checklist distilled from the most recent citations.
Beta · AI-generated — for reference only, not professional advice. Verify against current CMS guidance before relying on it. Assisto accepts no responsibility for how this checklist is used.