Failure to Plan and Document Safe, Goal-Directed Transfers and Discharges
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
Resources
Below are regulatory guidelines relevant to this citation:
A resident with multiple chronic conditions and moderate cognitive impairment was discharged home without the facility involving her POA in the discharge planning process, despite documentation that the POA had previously provided input favoring long-term placement and a care plan intervention for social services to meet with both resident and family to determine the discharge plan. The resident met with a PA, signed a discharge packet with medication and home health orders, and was picked up by family on the day of discharge, but there was no documented consultation or prior notification to the POA. The DON acknowledged that the family was not included in the discharge discussion, which conflicted with the facility’s discharge planning policy requiring collaborative planning and documentation of resident and representative notification.
A resident with multiple chronic conditions, who was assessed as cognitively intact, was discharged without any documentation in the medical record of their discharge disposition, recapitulation of stay, or discharge arrangements. The record lacked a discharge summary, nursing discharge note, and post-discharge plan of care. The DON confirmed these omissions, which were inconsistent with the facility’s own policy requiring nursing to obtain discharge orders, prepare a discharge summary and post-discharge plan, and complete a discharge note prior to discharge.
A resident with multiple complex conditions and severe cognitive impairment was issued a NOMNC by phone, then transferred to the hospital for elevated heart rate. The transfer form contained only clinical information and lacked evidence of a written transfer/discharge notice. The resident was taken off the census the same day, and after the BFCC-QIO later upheld the end of Medicare coverage, there was no documentation that the resident or representative was offered the option to return or stay on a private-pay basis or informed of service costs. The Administrator confirmed that no bed-hold notice or option to hold the bed was provided, the bed was not held during hospitalization, and the bed was reassigned so no bed was available when the resident was ready to return.
A resident with multiple chronic conditions, cognitively intact and dependent for ADLs with tube feeding, was transferred to the hospital, readmitted, and later given a 30‑day discharge notice. Social Services informed the resident’s daughter that there were no remaining bed hold days and that the resident would return as skilled, and later mailed a discharge notice stating the resident’s welfare and needs could no longer be met. The RSC later acknowledged the true basis for the discharge was concern about lack of a payer source and that the form was completed incorrectly. The RBOM confirmed the stay was still covered by managed Medicaid through a specified approval period when the notice was issued and that no bill for non‑payment had been sent, despite facility policy limiting discharge to defined causes such as inability to meet needs or failure to pay.
A resident with dementia, DM2, encephalopathy, and PTSD was sent to a psychiatric hospital after physically assaulting staff and other residents, with the facility’s transfer log indicating an expected return. The facility later decided on an immediate involuntary discharge due to safety concerns but did not notify the resident’s representative in advance, provide written notice, or offer appeal rights. On the day of discharge, the facility transported the resident from the psychiatric hospital to the representative’s home without documented discharge planning, interdisciplinary evaluation, or assessment of the home’s suitability, and the representative, who was already caring for an elderly parent, refused to accept the resident. The facility’s actions did not follow its own discharge planning policy requiring involvement of the resident/representative and ensuring the discharge destination met health, safety needs, and preferences.
A resident with complex medical needs and limited self-care abilities was discharged from the facility to a homeless shelter without adequate notice, preparation, or discharge planning. The resident did not receive necessary diabetic teaching, lacked essential supplies, and was not provided with assistance to secure income or housing. The homeless shelter lacked medical staff and could only provide temporary accommodation, and the resident was unaware of the discharge until the day it occurred. Facility staff did not notify the Ombudsman or provide proper documentation of the discharge process.
Failure to Involve POA in Discharge Planning
Penalty
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.
Failure to Document Resident Discharge Disposition and Post-Discharge Plan
Penalty
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.
Failure to Provide Bed-Hold Notice and Permit Resident Return After Hospitalization
Penalty
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.
Inappropriate 30‑Day Discharge Notice Issued Without Proper Cause
Penalty
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.
Failure to Provide Notice and Safe Discharge Planning for Involuntary Discharge
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe and properly planned discharge for a resident with dementia, type 2 diabetes mellitus, and encephalopathy whose wife was the responsible party. The resident was admitted on 07/11/25 and, on 11/29/25, received a pink slip due to physical aggression with staff and was transported by facility bus to a psychiatric hospital, with the transfer log indicating an expected return. A physician progress note dated 12/01/25 documented that the resident had spontaneously pushed two residents and physically struck a staff member and stated that an immediate discharge would be appropriate to prevent harm to residents or staff. The facility was aware of the planned immediate discharge from the psychiatric hospital but did not provide documentation that the resident’s representative was notified of an impending involuntary discharge, given written notice, or afforded appeal rights prior to the discharge. On 12/16/25, the facility picked the resident up from the psychiatric hospital and transported him by facility bus to his representative’s home address, despite no documented discharge planning, interdisciplinary evaluation, or assessment of the safety or appropriateness of the discharge location. The representative did not answer the door but communicated with the resident and the former Administrator via doorbell camera, and the Administrator then had the resident transported to a local hospital because the wife would not take him back and he could not return to the facility. The resident’s representative reported she had not been notified in advance that the facility would not accept the resident’s return, was not given the opportunity to appeal the discharge, and was not able to prepare for his discharge. She also stated that frequent transfers between facilities triggered his PTSD and that her responsibility for caring for her elderly mother made her home unsuitable for his care. The facility’s own discharge planning policy required involvement of the resident and/or representative in discharge planning, provision of education and communication prior to discharge, and assurance that the discharge destination met the resident’s health and safety needs and preferences, which was not demonstrated in this case.
Failure to Ensure Safe and Appropriate Discharge Planning
Penalty
Summary
A deficiency occurred when a resident with complex medical needs, including type 1 diabetes mellitus, celiac disease, hypokalemia, degenerative disease of the nervous system, and long-term insulin use, was discharged from the facility to a homeless shelter after residing there for over 22 years. The resident had a history of impaired vision, required supervision with insulin administration, and had documented deficits in adaptive functioning and executive skills. Despite these needs, there was no evidence of discharge planning, diabetic teaching, or preparation for self-care documented in the medical record prior to discharge. The resident was not provided with sufficient notice or preparation for the discharge, and there was no documentation of attempts to secure income, alternative housing, or necessary identification documents. The homeless shelter to which the resident was discharged did not have medically trained staff, only allowed a maximum 90-day stay, and had recently lost funding for programs that could assist with housing. Upon arrival, the resident lacked essential supplies such as insulin needles, which were only provided days later. The shelter staff and executive director expressed concerns that the resident lacked the life skills, income, and resources to care for himself and that the shelter was not an appropriate or safe discharge location. The resident missed a scheduled follow-up medical appointment due to lack of transportation arrangements, and interviews confirmed that he was unaware of the discharge plan until the day of transfer. Facility staff, including the DON and social services, confirmed that no discharge notice was provided to the resident or the Ombudsman, and that the discharge was prompted by insurance denial of payment for continued stay. Multiple interviews with staff, the resident, and external parties revealed that the discharge process was abrupt, lacked proper planning, and failed to ensure the resident's needs and preferences were met. There was no evidence of interdisciplinary team involvement or adequate preparation for the resident's transition to the community.
Removal Plan
- The Administrator immediately reviewed the last 30 days of discharges to ensure safe discharges occurred. No other areas of concern were noted.
- Follow up contact was made to Resident #83, #84, #85, #86, #87, and #88 who were discharged in the last 30 days. No concerns regarding discharge and no additional needs were identified by each resident.
- The Administrator immediately reviewed the pending discharges for Resident #16 and Resident #26 to ensure safe discharges plans with no other areas of concern noted.
- Social Services Director #180 and/or designee will notify the Ombudsman of the date the discharge notice is given.
- An in-service regarding the discharge process was completed by the Administrator with Social Services Director #180 that addressed the following: Except as specified below, a resident, and/or his or her representative will be given advance notice of an impending transfer or discharge from our facility: The transfer is necessary for the residents' welfare and the residents' needs cannot be met in the facility. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the residents no longer need the services provided by the facility. The safety of individuals in the facility is endangered due to clinical or behavioral status of the residents. The health of individuals in the facility would otherwise be endangered. The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. An immediate transfer or discharge is required by the residents' urgent medical needs. The resident is transferred for other than medical reasons. The resident has not resided in the facility for thirty days; and/or the facility ceases operating. The resident, and/or representative will be provided with the following information: The facility will send a copy of the discharge notice to a representative of the Office of the State Long-Term Care Ombudsman. The reason for the transfer or discharge. The effective date of the transfer or discharge. The location to which the resident is being transferred or discharged. The name, address, and telephone number of the state long-term care ombudsman. The name, address, and telephone number of each individual or agency responsible and the name, address, and telephone number of the state department agency that has been designated to handle appeals of transfers and discharge notices. The facility will not transfer or discharge the resident while an appeal for discharge is pending, unless the failure to discharge or transfer will endanger the health or safety of the resident or other individuals in the facility.
- A Quality Assurance and Performance Improvement (QAPI) meeting with the Administrator, Director of Nursing, Medical Director #275 and SSD #180 was held to review the discharge policy and procedure. No changes were made to the discharge policy and procedure at this time.
- The Facility Administrator was in-serviced by President of Operations #375 regarding the discharge process, required notifications, required notices, and preparation and orientation for discharge.
- A full Intradisciplinary Team (IDT) meeting was held which included the Administrator, DON, SSD #180, Business Office Manager (BOM) #152, Assistant Director of Nursing (ADON) #166, and Activity Director #128 regarding the discharge process, required notifications, required notices, and preparation and orientation for discharge that addressed the following: Except as specified below, a resident, and/or his or her representative will be given advance notice of an impending transfer or discharge from our facility: The transfer is necessary for the residents' welfare and the residents' needs cannot be met in the facility. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the residents no longer need the services provided by the facility. The safety of individuals in the facility is endangered due to clinical or behavioral status of the residents. The health of individuals in the facility would otherwise be endangered. The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. An immediate transfer or discharge is required by the residents' urgent medical needs. The resident is transferred for other than medical reasons. The resident has not resided in the facility for thirty days; and/or the facility ceases operating. The resident, and/or representative will be provided with the following information: The facility will send a copy of the discharge notice to a representative of the Office of the State Long-Term Care Ombudsman. The reason for the transfer or discharge. The effective date of the transfer or discharge. The location to which the resident is being transferred or discharged. The name, address, and telephone number of the state long-term care ombudsman. The name, address, and telephone number of each individual or agency responsible and the name, address, and telephone number of the state department agency that has been designated to handle appeals of transfers and discharge notices. The facility will not transfer or discharge the resident while an appeal for discharge is pending, unless the failure to discharge or transfer will endanger the health or safety of the resident or other individuals in the facility.
- A full house education was done by the Administrator and DON regarding the discharge process, required notifications, required notices, and preparation and orientation for discharge.
- Pending discharges will be discussed in the Stand-up Meeting daily Monday-Friday on business days, discharges pending for the weekends or holidays will be covered in the meeting Monday-Friday by Friday, with the IDT to ensure safe discharge plans and teaching or other needs. The IDT includes the following: Administrator, DON, ADON #166, BOM #152, SSD #180, and Activity Director #128. In the absence of one of these team members the other team members will act on their behalf.
- The Administrator, DON, or SSD #180 will notify Medical Director #275 of any pending discharge plans daily Monday-Friday on business days, discharges pending for the weekends or holidays will be covered in the meeting Monday-Friday by Friday.
- Pending discharge plans will be reviewed by the Administrator and/or designee and Director of Nursing and/or designee in Stand-up Meeting at least 3 times weekly for 6 weeks to ensure safe discharge plans have been made.
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.