Failure to Ensure Safe and Individualized Transfer/Discharge

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure that an immediate discharge was accurately documented and included in the medical record for a resident with severe cognitive impairment and significant behavioral symptoms. The resident had vascular dementia, major depressive disorder, alcohol dependence with alcohol-induced persisting dementia, anxiety disorders, and generalized anxiety disorder, and required maximum assistance for most personal care. Physician orders included multiple psychotropic and mood-stabilizing medications, and an order for the resident to reside on a secured unit. The quarterly MDS documented severe cognitive impairment, hallucinations, delusions, physical behaviors toward others, other behavioral symptoms, rejection of care, and wandering. From admission through discharge, nursing progress notes described escalating agitation and disruptive behaviors, including wandering into other residents’ rooms, placing items in toilets, exit-seeking, refusal of medications, and increasing aggression when redirected. The resident engaged in repeated episodes of public disrobing, inappropriate urination and defecation, and sexually inappropriate behaviors, such as entering female residents’ rooms naked and engaging in inappropriate sexual behavior on their beds, and attempting to rub feces on other residents. The resident was transferred twice for psychiatric evaluation due to behaviors the facility was unable to manage, including anxiety, aggression, exit seeking, sexual aggression toward females, and combative behavior resulting in self-inflicted injury. Despite these events, no interdisciplinary team notes discussing the resident’s behaviors were found in the record during the resident’s stay. On one evening, an LPN documented that the resident was in the hallway with genitals exposed, refused redirection to dress, became physically aggressive, and ripped the LPN’s shirt and pulled out her hair. The resident then entered a female resident’s room naked, claimed she was his wife, and forcefully attempted to get into her bed, causing the female resident to fall out of bed while trying to get away. Emergency services were contacted, and both residents were transferred to the ER for evaluation. After this event, there was no further documentation in the nursing progress notes regarding the resident’s discharge disposition. The Administrator later stated that an emergency discharge was issued due to the resident’s behaviors endangering others, but review of the electronic health record revealed no documentation of the immediate discharge, no record that the resident’s wife had been informed of the discharge and its reasons, and no scanned copy of the discharge notice. Further review showed that a written discharge notice, dated two days after the incident, inaccurately listed the discharge location as the family home, even though the resident had been transported to the hospital and did not return to the facility. The notice stated that the discharge was immediate due to behaviors endangering the safety of individuals in the home and included information on appeal rights and contact information for the Ombudsman and Administrator. The Administrator produced a separate folder containing a copy of the certified mail to the resident’s wife, an undated and unsigned note about a voicemail to the receiving facility’s social worker stating the resident could not return, and a narrative that the wife was notified of the emergent discharge and believed he would do better on an all-male secured unit. However, the Administrator confirmed that this information and the discharge notice had not been documented or scanned into the resident’s electronic health record, contrary to the facility’s Discharge/Transfer policy, which requires that unplanned discharge information and rationale be documented in the electronic record. The facility’s Discharge/Transfer policy, last revised in June 2025, outlined acceptable rationales for discharge or transfer, including behavioral issues that cannot be safely managed and that endanger others, and required that when unplanned discharges occur, the facility provide specific information in the discharge notice explaining why the resident is being discharged and how the discharge meets criteria, with this information documented in the resident’s electronic health record. In this case, the surveyors found that the facility failed to ensure the immediate discharge was accurately documented in the medical record and that the discharge notice contained accurate information about the discharge location, resulting in a deficiency for failure to ensure the transfer/discharge process met requirements for documentation and accuracy for this resident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to include a resident’s family/Power of Attorney (POA) in the discharge planning process, contrary to the resident’s care plan and facility policy. The resident had multiple complex medical diagnoses, including encephalopathy, peripheral vascular disease, malnutrition, acute and chronic respiratory failure, emphysema, congestive heart failure, chronic kidney disease, and other chronic conditions, and had a BIMS score of 10 indicating moderate cognitive impairment. A care conference document showed the current discharge plan was for the resident to remain in the facility for long-term placement, with the resident present but her family not in attendance. The resident’s care plan documented that she wished to return to the community, but also reflected that, per the POA, she was considered a possible long-term placement. The care plan included an intervention that social services would meet with the resident and family on admission to determine the discharge plan. Progress notes showed that the resident met with a physician assistant to discuss an upcoming discharge home and that both the resident and the physician assistant signed the discharge packet, which included medication orders and home health orders. However, review of progress notes for the days leading up to the discharge revealed no evidence that the facility consulted with or notified the resident’s family or POA about the discharge prior to the day it occurred, when the family member received a call from the resident to pick her up. The family member, who confirmed she was the POA and wanted to be kept up to date on all care and changes, reported that she had not been consulted about this discharge and that prior notifications had been inconsistent. The DON confirmed that the discharge process had not been discussed with the family before it occurred, despite the care plan and the facility’s discharge planning policy requiring collaborative planning with the resident and representative and documentation of resident and representative notification.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to document a resident’s discharge disposition and required discharge information in the medical record. Surveyors reviewed the closed medical record of a resident who had been admitted with diagnoses including breast cancer, hypertension, major depressive disorder, and osteoarthritis. The resident was documented as cognitively intact on a quarterly MDS assessment completed shortly before discharge. Despite this, the record lacked documentation of where the resident went after discharge and did not contain the required discharge-related entries. Further review of the resident’s closed record showed there was no recapitulation of the resident’s stay and no progress notes concerning discharge arrangements. The medical record did not include a discharge summary or a post-discharge plan of care, and there was no nursing discharge note describing the resident’s disposition. These omissions meant that the medical record did not reflect the basis for the discharge, the discharge planning process, or the resident’s post-discharge care arrangements as required by regulation. During an interview, the DON confirmed that there was no documentation of the resident’s discharge disposition in the medical record. The DON also confirmed that there was no documented recapitulation of the stay and no nursing notes about the resident’s discharge disposition, and that a post-discharge plan was not documented. Review of the facility’s policy titled “Transfer or Discharge, Preparing a Resident for,” revised in 2016, showed that the policy requires development of a post-discharge plan for each resident prior to transfer or discharge, review of this plan with the resident and/or family at least 24 hours before discharge, and that nursing services are responsible for obtaining discharge orders, preparing the discharge summary and post-discharge plan, and completing a discharge note in the medical record. These required elements were not present in this resident’s record.

Plan Of Correction

F627 Inappropriate Discharge The PoC will what corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident # 53 no longer resides in the facility. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. All residents residing in the facility have the potential to be discharged. Census of 47. There are currently no residents being discharged from the facility as of 3/25/26 sweep completed by nurse manager. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur. DON/designee in-serviced nursing management staff and social worker completed on 4/9/2026 a post-discharge plan is developed for each resident prior to his or her transfer or discharge. This plan will be reviewed with the resident, and/or his or her family, at least twenty-four (24) hours before the resident's discharge or transfer from the facility. Nursing services is responsible for obtaining orders for discharge or transfer, as well as the recommended discharge services and equipment, preparing the discharge summary and post-discharge plan, and completing discharge notes in the medical record. How the corrective action will be monitored to ensure the deficient practice will not recur. An audit of all discharged residents for a proper discharge plan and documentation is in place 5x a week X4 weeks per DON/designee. If there are concerns identified with the discharge audit, the concern will be corrected at that time, and the nurse involved will be educated in the area of improvement. Results are presented to QAPI team weekly to evaluate areas of improvement.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to permit a resident to return after hospitalization and to provide required transfer/discharge and bed-hold notices. The resident, who had multiple complex diagnoses including nontraumatic intracerebral hemorrhage, atherosclerotic heart disease, hypertension, dysphagia, cognitive communication deficit, muscle weakness, gait abnormalities, and severe cognitive impairment (BIMS score of two), was admitted to the facility in early January. A Notice of Medicare Non-Coverage (NOMNC) was issued by social services via telephone to the resident’s responsible party, advising that Medicare coverage would end and that financial liability would begin on a specified date, and informing them of appeal rights. The resident was then transferred to the hospital for elevated heart rate and admitted for observation and treatment. The transfer documentation reflected only clinical and communication information sent to the hospital and did not show that a written notice of transfer or discharge was provided to the resident or representative at the time of transfer. The resident’s record showed that the resident was discharged from the facility and removed from the census on the same day as the hospital transfer. A subsequent BFCC-QIO determination letter documented that the resident lost the appeal of the NOMNC and no longer met Medicare coverage requirements for SNF services, and that the resident or representative was notified by telephone of the decision and of financial responsibility for continued services after Medicare coverage ended. However, there was no documentation in the medical record that the resident or representative was offered the option to return or remain at the facility on a private-pay basis or informed of the cost of services once Medicare coverage ended. The Administrator confirmed that no bed-hold notice was provided, no option to hold the bed was offered when the resident went to the hospital, the bed was not held during the hospitalization, and that by the time the resident was ready to return, the bed had been given to another resident and no bed was available for readmission.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide and document sufficient preparation and planning to ensure safe and orderly transfers and discharges, and to ensure the discharge planning process addressed each resident’s discharge goals and needs. For one resident with alcohol dependence in remission, COPD, and rheumatoid arthritis, the care plan identified a history of substance abuse and anticipated that he would purchase and drink alcohol at the facility, with interventions to monitor for misuse and notify the physician if there were concerns. His social service evaluation and care plan documented that he was admitted for skilled services and planned to discharge to the community with his daughter, with a goal of a safe transition back to the community and interventions including involving home care agencies and community supports and providing written discharge instructions. On a later date, nursing notes documented that this resident fell in the hallway, hit his head on the medication cart, and was under the influence of alcohol, with an abrasion to his left eyebrow. He was alert and oriented and refused transfer to the hospital, and neuro checks were initiated. Shortly afterward, the nurse documented that report was called to another nursing facility and that all medications were being sent with the resident. A late entry by the President of Clinical Services stated that the resident was transferred to another nursing facility per his request, even though he was noted to be intoxicated at the time. The discharge plan of care only stated that he was discharged to another nursing home and that a medication list was faxed, with no further documentation explaining how the transfer decision was made, why his prior plan to discharge to family was no longer in place, how the receiving facility was chosen, or how it would meet his needs differently. Additional documentation from the receiving facility showed that upon admission, staff there were uncertain about the amount of alcohol the resident had been consuming daily, what precautions to put in place given his limited access to alcohol, and had limited details about his fall. Later that evening, the resident complained of double vision, nausea, and had a prominent area above his left eyebrow, and he requested to go to the emergency room. Interviews at the sending facility revealed that the LPN observed the resident reeking of alcohol and appearing intoxicated, that the Administrator discussed his drinking and preferences with him, and that the Administrator did not know if the transfer had been discussed with the physician. The Administrator also stated that another facility had called asking if they had residents with behavior issues and that the resident had previously expressed a preference to move closer to another city, but the facility lacked staffing to find a placement where he wanted. There was no documentation in the record explaining the change from the original discharge plan to family, the rationale for the new facility choice, or how the transfer planning addressed his goals and needs. For a second resident with respiratory failure, alcoholic cirrhosis, diabetes, alcohol abuse, viral hepatitis, PTSD, and bipolar disorder, the physician documented that she had been admitted after a hospital stay for alcohol detoxification and hypoxia, with heavy alcohol consumption prior to admission and a history of alcohol withdrawal seizures, and that she wished to transfer to a VA inpatient rehab program when a bed became available. Social services documented that she had been accepted for an inpatient rehab program at the VA with a tentative transfer date, and that she had authorization from the VA to stay at the facility for 30 days until that transfer. A nursing note then documented that the resident came to the facility, picked up her belongings and ordered medications, and was educated on her discharge and follow-up visit at the VA, with no further documentation regarding the reason for the discharge. The Business Office Manager stated that when she left for the day, the plan remained for the resident to stay until transfer to the VA, and that a discharge would require a physician’s order or be handled as an against medical advice (AMA) discharge if the physician did not agree. The resident reported by telephone that she left the facility and went home, and that she was later admitted to the VA on the planned date. She stated that someone at the facility had talked to her about her leaving the facility every day to go home after therapy, and that after that conversation she decided to discharge home. The Director of Nursing confirmed there was no physician’s order to discharge the resident, no evidence the physician was aware of the discharge home, and that the discharge was not handled as an AMA discharge. The discharge plan of care only documented that the resident was discharged home, with no documentation explaining why she was discharged home instead of transferring to the VA as previously planned, and no evidence that the discharge planning process addressed her established discharge goals and needs.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility issuing an inappropriate 30‑day discharge notice to a resident without proper cause. The resident, admitted with multiple sclerosis, left hemiplegia, cerebral infarction, diabetes mellitus, and stage IV chronic kidney disease, was cognitively intact and dependent for bed mobility, bathing, toileting, and transfers, and received tube feeding per a quarterly MDS. The resident had been transferred to the hospital and then readmitted to the facility before ultimately being discharged to another facility. On the morning of 08/28/25, Social Services documented informing the resident’s daughter that the resident had no remaining bed hold days and would be returning as skilled, and that a list of facilities would be emailed. A nursing note later that day documented the resident’s arrival back to the facility. A subsequent Social Service note dated 09/03/25 documented that a 30‑day discharge notice was mailed to the resident’s daughter, stating the discharge was because the resident’s welfare and needs could no longer be met at the facility. The written Discharge Notice, dated 09/03/25, listed the discharge date as 10/03/25 to another SNF for the same stated reason. However, the Resident Service Coordinator later confirmed that the actual reason for issuing the 30‑day discharge notice was concern about lack of a payer source, not inability to meet the resident’s needs, and acknowledged the form was filled out incorrectly. The Regional Business Office Manager confirmed that the resident’s stay was covered by a managed Medicaid product approved from 08/23/25 to 09/11/25, that the Notice of Discharge was issued on 09/04/25 while coverage was still approved, and that no bill for non‑payment had been issued to the resident or representative at the time the notice was sent. The facility’s own policy allows discharge for specific reasons, including inability to meet needs or failure to pay, and requires proper written notice, but the documentation and interviews showed the stated discharge reason did not match the actual circumstances or policy criteria.