Health inspection·June 26, 2023

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure appropriate discharge information was documented in the medical record by the physician for one (Resident #1) of five residents reviewed for discharges. The facility failed to ensure documentaion was made by the physician for the basis of Resident #1's discharge and/or the specific resident needs that could not be met by the facility. This failure could place residents at risk of being discharged without a safe and effective transition of care, an accurate reason for discharge and inaccurate information communicated to the receiving health care institution or provider. Findings included: Record review of Resident #1's undated admission record revealed he was a [AGE] year-old male with a current admission date of 05/12/23 and a discharge date of 05/22/23. The resident's MDS assessment dated [DATE] reflected diagnoses included anxiety disorder, depression, Alzheimer's disease, non-Alzheimer's dementia, and post-traumatic stress disorder. Review of Resident #1's 30-day discharge notification dated 05/22/23 revealed the reason for the discharge was the facility had determined the resident was a danger to himself and to other residents. Review of Resident #1's progress notes dated 05/22/23 revealed the resident was combative with staff and had barricaded himself in the therapy office on 05/22/23. The resident was placed on 1:1 monitoring and subsequently orders were received to transfer Resident #1 to the hospital on [DATE]. Progress notes dated 05/22/23 reflected Resident #1 was transferred to the hospital on [DATE]. Review of Resident #1's psychiatric notes dated 05/22/23 revealed services were being terminated due to Resident #1 being transferred out of the facility due to ongoing aggression. The last date of service was 04/28/23 and services provided were psychiatric and medication evaluation. Th notes reflected the resident was not considered to be at risk of harm to self or others at the time services were terminated on 05/22/23. Further review of Resident #1' clinical records revealed there was no physician's documentation related to the basis for the discharge, specific resident needs that could not be met by the facility, attempts to meet the resident's needs and/or services that would be available at the receiving facility to meet the resident's needs. Page 1 of 2 675680 675680 06/26/2023 Brentwood Place One 3505 S Buckner Blvd Bldg 2 Dallas, TX 75227

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with the Administrator on 06/26/23 at 2:46 p.m. she stated there was no additional information or documentation related to Resident #1's discharge. Interview with Resident #1's primary physician (Physician A) on 06/26/23 at 3:51 p.m. he stated he had not participated in the decision to discharge Resident #1. He stated his understanding was that the resident was discharged to keep other residents safe. He further stated he did not fully understand what all documentation was required when a resident was discharged from the facility. Interview with the DON on 06/26/23 at 6:21 p.m. she stated she was not aware there was not physician documentation regarding Resident #1's discharge. She stated she saw the physician in the facility and assumed the physician had completed whatever documentation that was required. Interview with the Administrator on 06/26/23 at 6:26 p.m. she stated her expectations were for all required discharge documentation to be completed. She further stated she had only worked at the facility for two weeks and had no first-hand knowledge of Resident #1's discharge. Review of the facility's policy/procedure dated 06/2020 and entitled Transfer and Discharge revealed the purpose of the policy/procedure was to ensure residents were transferred and discharged from the facility in compliance with State and Federal laws and to complete, safe, and appropriate discharge planning and provide necessary information to the continuing care provider. The section entitled Documentation reflected when the facility anticipated a discharge the resident's medical record would contain written documentation from the attending physician if the resident was transferred or discharged because it was necessary for the resident's welfare and the resident's needs could not be met in the facility and/or because the safety of individuals in the facility were endangered by the resident's presence or the health of individuals in the facility would otherwise be endangered by the resident's presence. 675680 Page 2 of 2