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Based on review of policies and procedures, medical records, and patient and staff interviews, it was determined that the facility failed to ensure that an appropriate discharge plan was implemented for one patient (P) (P#1) of four patients reviewed (P#1, P#2, P#3, and P#4). Specifically, the facility failed to ensure that P#1 received discharge medications in a timely manner which led to P#1 not having medication from time of discharge on 11/1/25 until the medications were delivered on 11/5/25.


Findings include:


A review of the facility policy titled "Implementing Discharge Planning, " effective 8/7/25 revealed discharge planning allowed for comprehensive, interprofessional, and individualized communication and preparation based on the patient's needs and risks. It promoted optimal recovery, reduced the risk of readmission, and supported safe patient transfer to the home or to another health care setting. The procedure began with screening during initial admission assessment. A discharge plan was developed early in admission that involved the patient and family that were informed of the expected discharge date as soon as possible. Throughout admission, continuous assessment of the patient and family needs were managed prior to discharge such as the need for caregivers, finances, and community services. Both written and verbal discharge education was provided to the patient upon discharge.


A review of the facility policy titled "Nursing Patient Assessment/Reassessment Policy," number 18266318, effective 6/26/25 revealed discharge planning was a multidisciplinary hospital-wide process that began when the patient entered the hospital environment. Early assessment of potential discharge needs was accomplished using various screening tools. The discharge plan was regularly evaluated during the patient's hospitalization or timeliness and appropriateness. Upon discharge, all the identified needs in the interdisciplinary care plan was addressed by the appropriate discipline. Assessments were completed upon admission at a variety of entry points and continued throughout the hospital stay. The nurse reviewed assessment data each shift to determine the patient's progress towards discharge and to identify if new or modified interventions were necessary.


A review of the facility policy titled "Care Management Plan for Discharge Planning and Transitions of Care," number 19234400, effective 11/4/25 revealed the purpose was to define an interdisciplinary approach for identifying and providing for post-discharge needs and continuity of care for the patient and their families after discharge. Case management staff assessed high risk patients such as those that included homelessness, uninsured, underfunded, and with a length of stay greater than five days. Discharge planning was provided by, or under the supervision of a registered nurse, social worker, or other appropriately qualified personnel. Discharge planning evaluations were reviewed for the likely need of services that included home health services, specialized medical equipment and related supplies, pharmaceuticals and related supplies. Patients were assisted in making timely discharge plans in the event for the need for post-hospital transitional services. When an inpatient was discharged to another facility, the proper referral forms, transfer forms, and pertinent medical records, and discharge instructions accompanied the patient. Documentation of discharge planning and instructions were noted in the patient's medical record.


A review of the facility policy titled "Complaint/Grievance Process Policy," number 18204290, effective 5/20/25 revealed a complaint was made verbally to the organization by a patient or patient's representative that was resolved at the time of the complaint by staff present and the patient was satisfied. A grievance was a formal or informal written or verbal complaint that was made to the organization by a patient or the patient's representative regarding the patient's care. A written response was required for the initial acknowledgement of grievance within a timeframe of ten calendar days. If the grievance was not resolved, the investigation was not complete, and the facility responded to the patient that the facility was still working to resolve the complaint and that the facility would follow up with another written response within 30 calendar days.


A review of the facility's policy titled "Rights and Responsibilities of Patients Policy," number 16455823, last revised 8/22/24, revealed that all patients had the right to considerate, respectful care at all times and under all circumstances. The patient had the right to request consultation with a specialist. This should have been arranged through referral by the patient's attending physician. The patient had the right to refuse care. The patient was responsible for his/her actions and the outcomes of those actions if he/she refused treatment or did not follow the agreed upon treatment plan.


A review of medical record revealed that P#1 was admitted to the facility on 10/19/25 with a ground level fall with upper and lower extremity weakness.


A review of Case Manager (CM) CC's note on 10/24/25 at 11:00 a.m., revealed there were no acute rehabilitation charity beds available for P#1 to be discharged to. CM CC updated P#1 and his family.


A review of a social worker (SW)'s clinical note documented on 11/1/25 at 2:52 p.m., revealed that a family member requested that P#1 be set up with follow-up appointments and home health before discharge. The SW explained that home health could not be set up because P#1 was indigent. Continued review revealed that P#1's family or the personal care home (PCH) could set up the appointments.


A review of the discharge summary revealed that P#1 was prescribed the following home medications:
" amlodipine 2.5 mg tablets (relaxes and widens blood vessels to lower blood pressure) - one tablet by mouth in the morning
" Dexamethasone 4MG tablets (steroid that treats inflammation) - one tablet by mouth two times daily with meals for two days, then one tablet daily with breakfast for three days, then 1/2 tablet daily with breakfast for three days.
" dextran 70-hypromellose (PF)0.1 - 0.3% (lubricant used to relieve dry eye) -one drop into both eyes every three hours as needed.


A review of a clinical note dated 10/31/25 revealed that P#1 was transported to a Personal Care Home (PCH) using transportation on 11/1/25 at 2:00 p.m.


A review of the Director of Case Management (DOM) BB clinical notes documented on 11/1/25 at 2:52 p.m., revealed that she received a call from the PCH stating that they were not aware that P#1 used a condom catheter (external catheter that helps manage urine incontinence) and was upset that he was not sent with supplies. DOM BB documented that the bedside nurse called the PCH to give report but no answered the call.. DOM BB documented that the PCH could have asked for supplies at that time.


A review of the Manager of Case Management (MCM) AA's notes on 11/4/25 at 4:36 p.m., revealed that she sent a text message to the PCH broker (the owner of the company) asking if P#1's medications had been received. MCM AA did not receive a reply. Further review revealed that another social worker documented that she was notified by DOM BB that P#1 had not received his medication at the time of discharge on 11/1/25.


A review of case manager (CM) CC's clinical notes revealed the following timeline:
- 11/4/25 - 12:23 p.m. CM CC called and spoke to the pharmacy to verify if medication was delivered to the facility. The pharmacy only received the fax with the facilities vouchers for payment. The pharmacy representative stated that the electronic prescription went to another pharmacy, but they could pull the order over and have the medications filled and delivered to the facility that day.
- 12:34 CM CC called the PCH owner and updated her that P#1's medications would be delivered to the facility and that CM CC would also obtain condom catheters and a leg bag for P#1.
- 3:39 p.m. - P#1's medication was delivered by the pharmacy to CM CC at the facility.
- 3:47 p.m. - CM CC texted PCH broker and asked if she could pick up the medication. CM CC received no text or call back until 11/5/25 at 1:40 p.m. stating that the broker did not have her phone at the time of the text message.
- 11/5/25- 2:00 p.m. - CM CC dropped off P#1's medication to the PCH.


A continued review of the CM CC's note documented on 11/5/25 at 4:50 p.m., revealed that she reviewed P#1's discharge package that accompanied P#1 to the PCH and identified documents that did not belong to P#1.


During a telephone interview with the complainant on 12/2/25 at 12:50 p.m. she stated that she understood the discharge process for the facility because she was a case manager at one of their facilities. The complainant reported that P#1 was sent to the PCH without a cervical-collar (neck brace used for support) after having a fresh spinal cord injury. The complainant further reported that P#1 was not sent to the PCH home with his medication and was without medication from the time of discharge 11/1/25 to 11/5/25 when someone picked up medication and took it the PCH.


During an interview with the Manager of Case Management (MCM) AA on 12/1/25 at 2:42 p.m. in the conference room, she explained that one of her responsibilities as the MCM was to give assignments to case managers (CM). MCM AA further explained that her team was in charge of patients discharge planning. MCM AA reported that the facility only sent patients to personal care homes (PCH) that were licensed. MCM AA further reported that she requested an emailed copy of the license before sending patients the PCH.

MCM AA reported that she remembered P#1 and that his prescription was sent to the wrong pharmacy. MCM AA further reported that P#1 was discharged from the facility without his medication. MCM AA explained that once the prescription was sent to the correct pharmacy, she delivered it on 11/5/25 to the skilled PCH that P#1 was discharged to on 11/1/25. MCM AA acknowledged that P#1 should not have been discharged until his medication was delivered to the facility.


During an interview with the Director of Case Management (DCM) BB on 12/1/25 at 3:11 p.m. in the conference room, she explained that she was responsible for overseeing the case management department. DCM BB further explained that her team assessed and reassessed patients for discharge throughout their stay. DCM BB reported that she was aware that P#1 was a functional quadriplegic (partial or total loss of motor function in all four limbs and the torso) and had no insurance. DCM BB reported that her team tried to find P#1 a charity bed without success. DCM BB further reported that the personal care home (PCH) agreed to accept the patient under a contract with the hospital paying them for 90 days.
DCM BB explained that it is not policy for patients that are discharged to a PCH to leave with medication, but to have it within 24 hours. DCM BB acknowledged that P#1 did not get his medication within 24 hours.


During an interview with case manager (CM) CC on 12/2/25 at 9:32 a.m. in the conference room, she reported that her responsibilities included discharging patients. CM CC reported that she sent P#1's prescription to a pharmacy to be filled before discharge. CM CC further reported that the pharmacy typically delivered the medication to the patient but did not have anyone available to deliver the medication on 10/30/25. CM CC explained that patients were normally discharged from the facility with their medications. CM CC further reported that she did not work the next day when P#1 was discharged and was not aware if he received his medication.


An interview was conducted with social worker (SW) DD on 12/2/25 at 9:46 a.m. in the conference room. SW DD reported that her responsibilities included ensuring a safe discharge for patients by making sure that they had everything they needed to transition to another facility.


During an interview with P#1 on 12/2/25 at 12:38 p.m. in his room, he confirmed that he was first admitted to the facility 10/19/25 after a ground level fall. P#1 reported that staff in the emergency room (ER) mixed up his identity with another patient in the ER who had a similar injury to his. P#1 explained that he requested to have the surgery about eight days after his admission and was told that he missed the 'window period' to have surgery.
P#1 reported that case managers were mean to him and kept asking him where he was going for discharge and told him that he could not stay at the facility. P#1 reported that he believed case management was mean to him because he did not have insurance. P#1 further reported that at one point, one of the case managers told him to shut up and let her talk.
P#1 reported that he was discharged to a personal care home (PCH) in Fayetteville without medical supplies to include a condom catheter, cervical collar or medication. P#1 explained that he was placed in a room with another individual that was coughing. P#1 further explained that the PCH smelled like weed (slang for cannabis). P#1 reported that the PCH told him they were sending him back to the hospital on 11/5/25 because he could not control his bowels. P#1 further reported that he was sent back to the ER by ambulance and has since had spinal surgery.


During an additional interview with MCM AA on 12/2/25 at 12:31 p.m. she explained that case manager (CM) CC brought it to her attention the DOM BB that P#1 was not discharged with his home medication.


During a follow up interview with CM CC on 12/2/25 at 1:50 p.m. she explained that DOM BB alerted her that P#1 did not have his discharge medication sent with him to the PCH. CM CC reached out to the pharmacy that the facility partners with to inquire about P#1's medication. The pharmacy reported that they did not receive the prescription at their pharmacy but was able to go into the system and extract it. CM CC reported that she believed the prescription went to another affiliated pharmacy at a different address but does not know which one. CM CC revealed that the pharmacy the facility partnered with did bedside deliveries to patients in-house and before discharge.


During a follow-up interview with DOM BB on 12/2/25 at 2:08 p.m. she reported that she did not remember what prompted her to call the PCH 11/1/25 to see if P#1 received his discharge medication. She further reported that she did not hear back from the PCH broker who owned the business that day.