**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a notice of discharge was provided in writing, discharge planning was completed, and a resident's discharge was safe with continuity of care ensured for 1 of 3 residents reviewed for discharge. (Resident E) This deficient practice resulted in an unsafe discharge when the resident was transferred to a hospital waiting area without admission arrangements and no way to obtain nutrition through enteral feedings. The resident voiced feeling of hopelessness and felt others wanted him to die. The immediate jeopardy began on 12/24/24 when the facility discharged Resident E to a hospital waiting area. The Administrator and Regional Administrator were notified of the immediate jeopardy at 3:58 P.M. on 1/6/25. The immediate jeopardy was removed on 1/7/25, but the noncompliance remained at the lower scope and severity level of isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy Finding includes: The clinical record for Resident E was reviewed on 1/5/25 at 2:00 P.M. Resident E was admitted to the facility on [DATE] from an acute care facility following surgical repair of necrotizing pancreatitis. The resident's diagnoses included, but were not limited to, status post (s/p) perforation of the esophagus, acute pancreatitis with uninfected necrosis, gastroesophageal reflux disease with esophagitis, fistula of the stomach and duodenum, and gastrostomy placement. The resident had a gastrostomy/jejunostomy tube (a GJ tube - combination of a tube placed in the stomach and a tube placed in the jejunum that is secured with a balloon or plastic bumper in the stomach and a plastic disc around the outside of the body.) The resident was admitted with physician orders for enteral tube feedings and nothing by mouth (NPO) except diet soda and medications. The acute care transfer documentation indicated the plan was for the resident to receive nutrition via an enteral tube feeding in the extended care facility until a gastrointestinal surgical consult was completed in four weeks. The resident was to have a Computerized Tomography (CT) scan performed in two weeks. The surgical note indicated in January, the resident's condition was to be reevaluated, a cholecystectomy performed, surgical repair of the resident's intestinal system performed and the G/J tube removed. The admission Minimum Data Set (MDS) assessment, completed on 11/30/24, indicated the resident was admitted for short stay rehabilitation from an acute care facility. The assessment indicated the resident was cognitively intact, had not displayed any mood issues or behaviors during the assessment period, was dependent on staff for feeding due to requiring enteral feedings, utilized a walker and/or wheelchair for mobility needs, required moderate staff assistance for lower body dressing, applying footwear, and bathing needs, received physical and occupational therapy and did not require an active discharge plan. An admission Care plan meeting note, completed on 11/29/24 at 11:01 A.M., indicated the resident attended the meeting and both sisters had participated via telephone. The resident was working with therapy to evaluate his ability to perform his own Activities of Daily Living (ADL) needs and the discharge goal was for the resident to discharge to an assisted living group home setting. There were no recommendations documented as a result of the care plan meeting. There was no further follow-up with discharge planning. A Discharge care plan for Resident E, dated 12/16/24 with a target date of 2/28/25, indicated the resident's goal was to discharge from the facility after a short-term stay. The focus indicated the resident planned to return home with a family member. The goals were for the resident to actively participate in therapy, as shown by his attendance and cooperation, and to have a safe discharge home. The only intervention listed for the plan was to assist the resident and family with discharge planning. A care plan, dated as revised on 12/5/24, indicated the resident was at risk for nutritional status deficit related to nothing by mouth (NPO) status and tube feeding for nutritional support. Interventions included, but were not limited to, tube feedings and flushes per the physician orders, monitor weights and laboratory values. During an interview, on 1/7/25 at 3:00 P.M., Employee 23 indicated the resident had been discharged from therapy services on 12/6/24, and the resident had remained at the facility. There were no nursing and/or social service progress notes regarding discharge needs until a Social Service Note, dated 12/23/24 at 2:35 P.M., indicated the Social Service Director (SSD) spoke with the resident and, via a phone call with one of the resident's sisters, informed the resident and his sister that the facility had nothing to skill the resident on, so he needed to leave because his insurance would not pay his bill. The resident informed the SSD he would be living on the streets. His sister was asked to come to the facility the following day for some training and the discharge. The resident's sister indicated she was going to call the State and bring them with her. Social Service Notes, dated 12/24/24 at 10:17 A.M. and 12/24/2024 at 4:21 P.M., indicated the SSD attempted to leave messages for both sisters regarding the resident's discharge time. A Social Service Note, dated 12/24/24 at 2:25 P.M., indicated one of the resident's sisters had left a phone message that the resident was to be transported to the local hospital because she refused to take him in. A follow-up entry from the SSD, dated 12/24/24 at 2:19 P.M., indicated the resident wanted to go to the local hospital to speak with his doctors and then he planned to get a bus ticket out of the state to go to his sister's. There was no documentation in the record that indicated the resident had any prior communication about wanting to discharge until he was informed he would have to leave. There was no documentation in the record to indicate the SSD or any other staff attempted to provide any written notice of discharge, services for discharge planning, or services to ensure continuity of care to the resident or family. The physician's orders for Resident E lacked an order to discharge the resident from the facility. During an interview on 1/6/25 at 3:36 P.M., the Medical Director indicated he had not been notified nor had any record of ordering a discharge for Resident E. A Nursing Progress Note, dated 12/24/24 at 4:12 P.M., indicated the resident was transported by the facility transporter to the local hospital as requested by the resident. However, a Nursing Progress Note, dated 12/24/24 at 4:14 P.M., indicated the resident was discharged to home. A Resident Discharge Summary, completed on 12/24/24 by the Director of Nursing (DON), indicated Resident E was discharged to Home/Community accompanied by his family - sister/family to drive him home. The resident was given discharge instructions and discharged with all of his personal belongings but declined education on his gastronomy tube. The resident was quoted as stating I am going to be dropped off at [name of local hospital] and they will take it [gastronomy tube] out for me. No community resources were listed and 'None Needed was marked. Additional comments on the form were as follows, Resident is discharging because we can no longer skill his services. He has no forwarding address so home health cannot be scheduled. A Nursing Progress Note, dated 12/24/24 at 6:10 P.M., indicated the facility received a phone call from a nearby community police department. They informed the facility that Resident E was at the local hospital and claimed he had been kicked out of the long-term care facility and they had dumped him off at the hospital. The facility nurse documented she had corrected the officer and informed him the resident was discharged from the facility because his insurance had cut him off and his sister had refused to come get him. She indicated the resident had requested to go to the local hospital because of his feeding tube. A (Name of Hospital) admission note indicated the resident arrived at the hospital on [DATE] at 4:38 P.M. for feeding tube issue. The emergency room (ER) note indicated the resident presented with complaints, .they discharged me from the [name of facility] rehab [rehabilitation] today and I have no place to go .I have this feeding tube in place and I am forced to be outside tonight, it could freeze and freeze my internal organs .I need to be readmitted . The note indicated the resident was evaluated and, .differential diagnostic consideration include social situation of him being homeless tonight on Christmas Eve. Unfortunately, my care coordinators have left for the day as it is after 5 p.m The case was discussed with the house supervisor and there was no medical need for an inpatient stay. He was safe to discharge. A (Name of Hospital) ER note, dated 12/25/24, indicated the resident presented to the ER with his sister. The resident had a history of complex medical history necrotizing pancreatitis with J tube feedings. He complained of feeling depressed due to his current situation, as he was unhoused. He was discharged from a nursing home two days ago. The sister indicated she had been calling everyone to try to get help. The resident indicated he was tube dependent and had not had any feedings for the past two days and was discharged without any equipment. The note indicated, .Patient is feeling hopeless because he feels like everyone in the state of Indiana wants him to crawl in a ditch and die .Patient is feeling depressed and hopeless like he would be better off dead .I do not feel comfortable discharging him home because he has no way to get nutrition The (facility name) was contacted and indicated the resident was transported to the ER yesterday because he had no home, and family would not pick him up. He was not prescribed any feedings and there were no definite arrangements that staff were aware of and they would fax the discharge summary. A (Name of Hospital) Discharge Note indicated the resident arrived at the hospital on [DATE] at 4:27 P.M., after making suicidal statements. The documentation indicated the resident had been in the acute care facility for a prolonged stay, was discharged to the long-term care facility with tube feedings to be continued, and a GI (gastro-intestinal) physician follow-up to have occurred in January 2025. The note indicated the resident was discharged from the long-term care facility but was homeless with nothing set up for his tube feedings. The note indicated he was unable to go to any of the homeless shelters in the area due to the tube feeding, and so he had presented to the emergency department feeling hopeless. The emergency room note indicated the resident was not able to take in nutrition orally and had complex social issues. The resident was evaluated in the emergency room by psychiatry due to the suicidal comments he had made and deemed not actively suicidal, but just feeling hopeless due to his situation. The resident was admitted to the acute care facility with diagnoses including, but not limited to, cellulitis of the lower extremities with antibiotic therapy ordered and continued need for jejunal nocturnal (night) tube feedings for nutritional needs. On admission, he also had bilateral lower extremity deep vein thrombosis (a condition that occurs when a blood clot forms in a vein deep inside a part of the body) and was treated with heparin (a blood thinner). The resident was discharged from the hospital on 1/3/25. During a confidential telephone interview, on 1/5/2025 at 11:30 A.M., the interviewee indicated the resident and his family members were informed on 12/23/24 that the resident's insurance had cut him and would not pay the bill for the resident to stay at the facility. The complainant indicated the resident was not given any prior notice and/or documentation regarding an impending discharge. During an interview with the SSD, on 1/5/25 at 4:10 P.M., she indicated during the admission Care Plan Meeting, the resident's sisters had informed her the discharge goal was for the resident to go to a group home setting. She indicated she had informed the sisters that the resident did not have any qualifying diagnoses for a group home admission and the process to admit someone to a group home took up to six months to complete. She indicated the plan was for the resident to discharge to his sister's home but when she notified them on 12/23/24 of the resident's need to be discharged on 12/24/24, both sisters indicated he could not stay with them. She indicated the resident asked to be discharged to the hospital because his car was there. The SSD indicated she told the resident and his sisters he had to leave because he had been discharged from therapy services and the facility had no skilled service for him. When asked about his payor source or if there was a letter from the resident's insurance of his notice of eligibility change, the SSD indicated she did not pay attention to resident's payor sources and she was not aware of any cut letters (from Resident E's insurance) or any NOMNC (Notice of Medicare/Medicaid Non-Coverage form) being provided for Resident E. When asked if the resident was given a written 30-day discharge notice, the SSD indicated she was not familiar with the form. When asked if the local hospital had been informed of Resident E's desire to be taken to the hospital and if any paperwork had been faxed to the local hospital, the SSD indicated nursing would have taken care of those types of things and she was unsure if any communication had been given to the local hospital regarding Resident E. When asked if there were any more discharge planning notes or documentation for Resident E, the SSD indicated the only notes were the ones provided in the electronic record progress notes. During an interview, on 1/6/25 at 11:00 A.M., the DON indicated she had completed the discharge forms and instructions for Resident E on 12/24/24. She thought the resident was being discharged due to an insurance thing, as rehabilitation-wise, the facility had nothing to skill him on. The DON had attempted to teach him how to use his PEG tube, but he refused all teaching and refused to take any tube feeding with him because he was going straight to the hospital to have the tube removed. When asked if the hospital was notified of his desire to go to the hospital, and a interfacility transfer set up with the hospital, the DON stated No, he was being discharged to the hospital parking lot because that was where his car was located. The DON indicated she had sent his prescriptions for medication to a local pharmacy, but the resident told her he was probably not going to go get his medications because he did not have any money for them. She indicated she had sent a three-day supply of medications with him and gave him instructions for the medications. The DON indicated usually the SSD and the Assistant Director of Nursing (ADON) completed discharge planning for residents and she was unsure what planning had been completed for Resident E prior to his discharge from the facility. The week of his discharge, the ADON was on vacation and the DON was not sure what planning the SSD had documented. During an interview, on 1/6/25 at 2:39 P.M., the Administrator indicated the resident was admitted for short-term rehabilitation to home. She understood home was to his sister's home in Michigan, as the resident was homeless otherwise. The Administrator thought the plan to discharge the resident to his sister's home in Michigan was documented on 12/4/24, but there was no documentation of this plan in the social service or nursing progress notes. The Administrator indicated the resident needed to discharge because he had been discharged from therapy services and the facility was not able to skill him for just his gastronomy tube. She then indicated that the resident desired to discharge from the facility before the holidays to spend them with his family. However, there was no social service and/or nursing progress note to support the resident's desire to discharge from the facility on 12/24/24 or any notes leading up to the holidays documenting the resident and/or his family's desire for him to be discharged prior to the holidays. The Administrator indicated the resident's sister in Texas had left a phone message insisting the resident be discharged to the local hospital. However, on 1/6/24 at 4:01 P.M., the Administrator had played part of the audible recorded phone message and the resident's sister clearly stated neither she nor her sister were able to take care of the resident, he was homeless, and she was very upset the facility was kicking him out before Christmas. During an interview with the facility transportation staff member, Employee 41, on 1/6/25 at 4:00 P.M., she indicated she had dropped Resident E off by himself at the main entrance to the local hospital and he had walked into the hospital carrying his suitcase. She was not aware of any paperwork sent to the hospital. During an interview with the Regional Administrator, on 1/6/25, she indicated that since the resident was discharged to the hospital, the discharge was safe. During an interview, on 1/7/25 at 12:40 P.M., the interviewee indicated her brother, herself and their other sister were informed on 12/23/24 that the resident needed to discharge because his insurance would not continue to pay. She indicated neither the family nor the resident were given any prior notice and offered any assistance in finding a place of discharge. The facility was informed that neither their sister nor her could get him due to living out of state. He was taken to the hospital and dropped off. None of them knew what else they could do. The resident was seen in the ER on [DATE] and was discharged . She indicated the security guard at the hospital was so upset that the resident had no place to go, the security guard bought him a one-night stay at a local hotel. The family did not see the resident until 12/25/24, when he was taken back to the hospital by the family. He was subsequently admitted to the hospital on [DATE]. She indicated this had been a horrible ordeal for her brother. He was currently in the hospital again with life threatening concerns. Resident E's government-provided insurance eligibility forms indicated Resident E was approved for long-term care skilled care through 12/26/24. The approval dates were given for short-term time periods and Resident E's stay had been approved from his admission through 12/26/24 at the time of his discharge on [DATE]. The facility policy and procedure, titled Transfer and Discharge Policy and Procedure provided by the Administrator as current on 1/6/25 at 9:05 A.M., included the following: 2. Non-emergency transfers or discharges not within the same certified facility will receive notice 30 days before transfer or discharge. Notice will be given to the resident/responsible party. 3. The written notice will include the following: a. A statement that the resident has the right to appeal the section to State Department of Health including a current phone number of the Department, b. The name, address and telephone number of the State Long Term Care Ombudsman, .d. A state that, if the resident may appeal the transfer or discharge to the Department of Health within 10 days of being notified of the transfer/discharge 4. The resident may remain in the facility pending an appeal determination or 34 days if the department agrees that the transfer is appropriate .6. The facility will provide provisions for continuity of care and in non-emergency situations a care plan meeting will be held with the appropriate parties to determine a relocation plan . Discharge to Home or lower level of care where resident or family will be administering the resident's medications . 2. The attending physician is required to write a discharge order. Telephone orders are acceptable .Discharge Against Medical Advice 1. When the resident wishes to go home or the resident's family/Responsible Party wishes to take the resident home and the attending physician refuses to give a discharge order a 'Discharge Against Medical Advice' form must be signed by the resident or the resident's representative and placed in the health record. 2. No transfer form completed . 4. The facility should determine the need to contact the appropriate State agencies if the resident's safety is a concern .Emergency Transfer: 1. Obtain physician order for transfer. If the attending physician is not available in an emergency, contact the alternate physician. 2. If the alternate physician is not available, contact the Medical Director. 3. If the Medical Director is not available, contact the Director of Nursing .5. Call ambulance for transfer. 6. Explain transfer and reason to the resident and/or representative, if applicable send the original State Transfer/Discharge/Bed hold notice with the resident and/or representative or person(s) responsible for care. Place the facility copy in the health record. 7. Complete the Resident Transfer for make 2 copies of any portion of the heath record necessary for care of resident (E.g. Physician's Orders, History & Physical, chest x-ray, Immunization information, any pertinent lab work, etc) 8. Send original of transfer form and portions of health record that was copies with the resident, attach the second copy of the portions of the health record to the facility copy of the transfer form. Give the third copy of the transfer form to the DON The immediate jeopardy that began on 12/24/24 was removed on 1/7/25, after the facility completed a complete audit of all discharges in the last three months and educated all licensed nursing staff, the Administrator and social service staff on the transfer discharge policy. The noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy, because the facility needed to ensure the education was effective by auditing discharges and following up on staff education with further education for the SSD. This citation relates to Complaint IN00448438. 3.1-12(a)(3) 3.1-12(a)(4) 3.1-12(a)(5)(B) 3.1-12(a)(6)(A) 3.1-12(a)(7) 3.1-12(a)(18) 3.1-12(a)(19) 3.1-12(a)(20) 3.1-12(a)(21) 3.1-12(a)(22)