Health inspection·August 1, 2025

F624 (Rev. 211; Issued: 02-03-23; Effective: 10-21-22; Implementation: 10-24-22) §483.15(c)(7) Orientation for transfer or discharge. A facility must provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. This orientation must be provided in a form and manner that the resident can understand. The facility failed to implement their discharge planning to include the resident for their preparation to effectively transition them to post-discharge care for Resident 1. Resident 1 did not have discharge care plans, interdisciplinary team (IDT, members of healthcare team that meets to discuss and plan resident care) meeting note addressing discharge planning, and referrals being sent to and accepted from shelters (temporary housing) and home health agencies (organization that provides skilled nursing and other therapeutic services to individuals in their homes). This failure resulted in unsafe discharges and placed residents at health and safety risks. Review of Resident 1's record indicated he had diagnoses including dementia (memory problem) with agitation, failure to thrive (progressive loss of physical and functional abilities, often accompanied by weight loss, poor appetite and inactivity) and anxiety (mental disorder). Review of Resident 1's hospital History and Physical Note, dated 9/21/24, indicated the resident was non-English speaking, had a history of behavior change, agitation and violent behavior against caregiver, had visual hallucinations (seeing images that are not actually present) and was highly suspicious for insidious progression of dementia. Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 11/11/24, indicated his Brief Interview for Mental Status (BIMS) was 3, indicating he had severe cognitive impairment in daily decision-making skills. Resident 1's MDS, dated 11/11/24 and 1/23/25, indicated there were no active discharge plan for the resident to return to the community. Review of Resident 1's Psychosocial Note, dated 11/8/24 at 2:19 p.m., indicated Resident 1 was being taken care of by a longtime friend, became physically violent over the 10 years, hurt the friend/caregiver and the caregiver wanted no contact with Resident 1. Review of Resident 1's Psychosocial Note, dated 1/20/25 at 2:56 p.m., indicated the resident stated he would like to be back in his hometown community. Review of Resident 1's Psychosocial Note, dated 1/21/25 at 11:12 a.m., indicated the resident had stated he would like to be transferred to a lower level of care, had no income, no family involved in care, and referrals were to be made to a home health agency and case manager for housing. Review of Resident 1's record did not contain discharge care plan, IDT discharge planning notes, referrals with information indicating resident status and acceptance from the shelter and home health agency. During an interview on 1/29/25 at 4:15 p.m., the regional social services director (RSSD) stated Resident 1 was discharged to a homeless shelter and the IDT met weekly discussing resident discharges. The RSSD also stated when a resident was being discharged there should be progress notes addressing discharge planning. During an interview on 3/27/25 at 12:30 p.m., the social services director (SSD) who documented Resident 1's Psychosocial Notes stated there should have been and were no discharge care plans, no IDT notes, no referrals and acceptances letter from shelters and home health agencies and no notes indicating resident participation in discharge planning. During a follow-up interview on 4/24/25 at 1:40 p.m., the RSSD stated as part of the discharge process the facility sends information such as resident history and physical, rehabilitation notes to shelters and home health agencies, and makes arrangements for sheltered individual as to where to meet for home services. When asked for supportive documentation the RSSD stated everything is done verbally over the phone. No discharge referral or documentation were provided. Resident 1's discharge documentation was requested from the assistant director of nurses (ADON) and/or SSD on 3/27/25, 4/24/25 and 5/15/25 and were not provided. Review of Resident 1's physician's order, dated 1/22/25, indicated the resident may be discharged to home with home health services. Resident 1 was discharged on 1/23/25 at 1:36 p.m. to a shelter. Review of Resident 1's face sheet (document that provides an overview of a residents' information and medical history) indicated the resident was readmitted to the facility on 1/30/25. Review of Resident 1's Physician Note, dated 2/6/25 at 12:25 p.m., indicated Resident 1 was readmitted due to dementia and was unable to care for himself. During an interview on 5/12/25 at 10:38 a.m., the administrator (ADM) stated the role of the ADM was to oversee residents' discharges were safe and to document ADM participation in resident progress and or IDT notes. The ADM stated he did not document discharge planning notes for Resident 1. During an interview on 5/14/25 at 2:30 p.m., the medical director (MD) stated did not know Resident 1 discharged to[DF1] shelter and given the residents' circumstances i.e., no income or family support the discharge may not have been safe. During an interview on 1/30/25 at 11:50 a.m., a staff member (SM) A from Resident 1's shelter stated when residing in the shelter individual needs[DF2] to check in daily by 5 p.m. and leave the next day by 9 a.m. and if a person had problem behavior they may not have a bed to return to. The SM A also said the shelter rarely received referral or accepted admission of elderly skilled nursing residents, they are a red flag. Review of the Facility-Initiated Transfer or Discharge policy, dated October 2022, indicated a post-discharge plan was developed for each resident prior to his or her discharge. This plan was to be reviewed by a member of the interdisciplinary team with the resident at least 24 hours before discharge. Sufficient preparation and orientation for the resident prior to an immediate facility-oriented discharge included explaining to the resident where he/she was going and why, taking steps to minimize anxiety or depression, and nursing notes were to include documentation of appropriate orientation and preparation prior to discharge. The policy also indicated information were to be communicated included the basis for discharge, all special instructions or precautions for ongoing care such as comprehensive care plan goals, resident status, diagnoses and allergies, medications. Review of the Comprehensive Person-Centered Care Plans policy, revised in March 2022, indicated each resident had the right to participate in the planning process and in establishing goals and outcomes of care. The facility failed to implement their discharge planning process includes the resident for their preparation to effectively transition them to post-discharge care for Resident 1. Resident 1 did not contain discharge care plans, interdisciplinary team meeting note addressing discharge planning, and referrals being sent to and accepted from shelters and home health agencies. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.