Based on interview and record review, the facility (Skilled Nursing Facility 1 [SNF 1]) failed to ensure a safe and orderly discharge was provided to one of three sampled residents (Resident 1), who exhibited behaviors that made Resident 1 a danger to himself (Resident 1) and others, and who was admitted to SNF 1, a locked facility (facility that cares for residents that utilize secured perimeter fences or locked exit doors) to Skilled Nursing Facility 2 (SNF 2), a non-locked facility (a facility that does not have secured or locked units) on [DATE] by:
1. Failing to ensure Registered Nurse 2 (RN 2) obtained a physician order from Medical Doctor 1 (MD 1- Resident 1 ' s attending physician) to discharge Resident 1 to SNF 2 on [DATE].
2. …
Based on interview and record review, the facility failed to ensure two of three sampled residents (Residents 1 and 2) were prepared for a safe discharge from the facility when the following occurred:
1. On [DATE], facility staff discharged Resident 1, who required extensive assistance with activities of daily living (ADLs, routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) and mobility, without arrangements for home health services (a wide range of health care services that you can get in your home for an illness or injury), as ordered by the physician.
2. …
D · No harm, potential for more than minimal, isolatedApril 17, 2025
Based on interviews and records review, the facility failed to provide sufficient discharge planning for one of three sampled residents (Resident 1) when the facility did not ensure needed home health services were in place prior to Resident 1's discharge.
This failure resulted in Resident 1 not being provided needed home services.
Findings:
During a review of Resident 1, admission Record (AR), dated 04/09/25, the AR indicated, Resident 1 is a [AGE] year old male, admitted on [DATE] with diagnoses that included, fracture of right acetabulum and right pubis (a break in the socket of the hip joint), fall-subsequent encounter, Type 2 Diabetes Mellitus (the body cannot use insulin correctly and sugar builds up in the blood), and long-term use of insulin. …
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