In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across Indiana. These citations represent the most serious level of noncompliance, where resident safety is at immediate risk. Understanding the patterns behind these citations can help providers proactively address vulnerabilities and improve care outcomes.
Top Areas of Noncompliance
There’s a handful of other areas, including F600 Free from Abuse and Neglect and F684 Quality of Care, but in this post, we’re going to focus on a discharge-related IJ cited under F622. While the tag number for F622 is no longer an active Ftag, these requirements remain in place and would likely now be cited under F627 Inappropriate Transfer/Discharge.
Let’s look at how this Indiana nursing home ended up being put into Immediate Jeopardy for an inappropriate discharge:
F622 S/S: J (Isolated)
A facility landed in IJ after it was identified that the facility discharged a resident to a hospital waiting area without admission arrangements and no way for the resident to obtain nutrition through enteral feedings. On interview, the resident stated that he felt hopeless and that others wanted him to die.
The resident had been admitted for a short term stay with a plan for the resident to receive nutrition via an enteral tube feeding at the facility until a GI surgical consult was completed in a month. Per the Admission Care Plan documentation, the resident was working with therapy to evaluate his ability to perform his own ADLs, and his discharge goal was to discharge to an assisted living group home setting. No further documentation regarding discharge planning was observed. The resident’s Discharge Care Plan, by contrast, indicated that the resident was to discharge home with a family member with an intervention to assist the resident and family with discharge planning.
The SOD then discusses how the Director of Social Work called the resident’s family and told them that he had been discharged from therapy, and his insurance was not going to pay for his stay, so he needed to leave. The resident told the Director of Social Work that he would be out on the streets if he was discharged. The resident’s sister was asked to come to the facility for training and to discharge the resident on the next day. Per facility staff, one of the resident’s family member told the Director of Social Work to transport the resident to the hospital because she would not take him in.
There were multiple issues surrounding this discharge, which we’re going to list out here since some facilities struggle to understand why a discharge isn’t appropriate:
- There was no documentation in the resident record that the resident had indicated he would be discharged until the time he was told he had to leave.
- There was no documentation that indicated facility staff attempted to provide. discharge planning services or assistance or services to ensure continuity of care for the family.
- There was no documentation that the facility attempted to provide a written notice of discharge.
- There was no evidence that the physician had been notified of the resident’s discharge and no corresponding physician’s discharge order.
- The Director of Social Work stated that she didn’t pay attention to the resident’s payor sources and wasn’t aware of any cut letters or a NOMNC being provided to the resident. A later review of the resident’s insurance paperwork found that the resident had been approved for additional days of coverage in excess of when he was discharged.
- The Director of Social Work stated she was “not familiar” with the 30-day discharge notice when asked if one had been issued.
- The Director of Nursing stated that resident was discharged to the hospital parking lot because that was where the resident’s car was located.
- The resident’s prescriptions were sent to the local pharmacy, but the resident told the Director of Nursing that he wouldn’t pick them up because he didn’t have any money for them.
- The Regional Administrator told the complaint investigator that since the resident was discharged to the hospital, the discharge was safe.
Compliance Insights
The bullet list you just reviewed is basically a how-not-do list of discharge planning. Nursing homes cannot discharge a resident to a hospital. That’s the long and short of it that you need to remember, but here are some other important reminders:
- Potential for Psychosocial Harm – The resident in the scenario we just reviewed presented to the hospital with suicidal comments and feelings of hopelessness and worthlessness. In this citation, the Psychosocial Outcome Severity Guide wasn’t applied to this citation specifically, but it sure could have been. The resident was homeless, and the facility had not addressed the need for his tube feeding. The SOD even documented that the hospital security guard felt so bad for the resident that he paid for him to stay in a hotel for one night.
- Documentation is Essential – This SOD is a great example of why I always tell staff responsible for discharge planning that they need to document, document, document. Most of the time, discharges go fine and are successful, right? Well, what about when something doesn’t go right? Do you have anything to back up what you say you’ve been doing? If not, you had better think twice about how you’re addressing your progress regarding a resident’s discharge efforts.
- Re-educate Staff regarding Notices & Timing – It’s never a bad idea to re-educate staff responsible for the various parts of discharge planning, which can sometimes cover multiple departments. Some facilities have MDS staff issue cut letters, and in others it can be the Finance department or Social Work. Responsible staff need to be aware of what documents, such as discharge notices, need to be issued – and when. Notification to the State LTC Ombudsman? Ensure that responsible staff knows the requirements.
Turn Survey Outcomes Into a Compliance Comeback
Whether you’ve received a citation (. . . or several) or just want to improve, CMSCG’s consulting team helps nursing homes rebuild stronger systems and prevent repeat deficiencies.
Let’s talk. Call (631) 692-4422 or visit cmscompliancegroup.com.
