DENVER, CO - A City Scape Rehabilitation & Care Center resident was discharged to a homeless shelter without proper documentation, medications, or legal protections after complaining about facility conditions, according to federal inspection findings.
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Improper Discharge Process Violated Federal Requirements
City Scape Rehabilitation & Care Center violated federal regulations when it forcibly discharged a cognitively intact resident in February 2024 without following mandatory procedures designed to protect nursing home residents from inappropriate removals.
The facility failed to provide the required 30-day written notice before the discharge, leaving Resident #105 without essential information about his rights or the reasons for his removal. Federal law requires nursing homes to provide detailed written notification that includes the specific reason for discharge, the effective date, the destination location, and comprehensive information about appeal rights.
The resident and his representative received no written documentation explaining why the facility was forcing him to leave or informing him of his legal right to challenge the decision. This violated the fundamental protection that ensures residents cannot be arbitrarily removed from their homes without due process.
Federal regulations also mandate that the state long-term care ombudsman receive a copy of any discharge notice simultaneously with the resident notification. The facility failed to provide this required communication to the ombudsman's office, further compromising oversight protections.
Medical Continuity Compromised During Discharge
The facility's discharge process created serious gaps in medical care continuity. Resident #105 was managing multiple chronic conditions including rheumatoid arthritis, anxiety disorder, depression, attention-deficit hyperactivity disorder, and chronic pain - all requiring ongoing medication management.
Despite facility policy requiring nurses to ensure residents receive their medications and understand proper usage during discharge, Resident #105 was sent to a homeless shelter without his prescribed medications or any discharge instructions. The Director of Nursing confirmed that standard protocol included medication reconciliation and patient education, but these critical safety measures were not implemented.
This medication discontinuity posed significant health risks. Sudden cessation of psychiatric medications like those used for anxiety and depression can trigger withdrawal symptoms, mood instability, and increased suicide risk. Rheumatoid arthritis medications require consistent dosing to prevent disease flares that can cause permanent joint damage.
The resident reported experiencing "a lot of confusion and anxiety" after leaving the facility and required subsequent hospitalization. This suggests the medication discontinuity may have contributed to clinical deterioration requiring emergency medical intervention.
Pattern of Retaliation Against Resident Complaints
Evidence suggests the discharge may have been retaliatory following the resident's complaints about facility conditions. Resident #105 had contacted police about heating issues, stating the facility's heater was turned off and he was cold. Within days of this complaint, the facility initiated discharge proceedings.
The resident's representative reported the discharge occurred immediately after he "spoke up about things that concerned him during his stay, such as the heat being turned off and being cold in the building and his clothing coming back from the laundry not cleaned or with holes."
This timing raises serious concerns about potential retaliation against residents who exercise their right to voice legitimate grievances about care conditions. Federal regulations explicitly protect residents' rights to file complaints without fear of retaliation or discrimination.
Facility Staff Unable to Explain Discharge Decision
Multiple facility administrators could not provide clear explanations for the discharge during the inspection interview. The nursing home administrator and regional operations consultant acknowledged they "could not give a reason why the discharge was facility-initiated" and stated they "did not know the reason why the facility discharged the resident."
This lack of clear rationale contradicts federal requirements that discharges be based on specific, documented criteria. Legitimate reasons for facility-initiated discharge include situations where the resident's needs cannot be met at the facility, non-payment after reasonable efforts to develop payment arrangements, or when the resident's presence endangers the health or safety of others.
The medical record contained conflicting information, with a physician's note mentioning behavioral concerns but the resident's formal assessment documenting no behavioral symptoms and no rejection of care. This inconsistency suggests inadequate documentation to support a legitimate discharge decision.
Psychological Impact and Subsequent Homelessness
The improper discharge process caused significant psychological distress. Resident #105 described the experience as "horrible" and "humiliating," stating it made him feel "like he was a huge problem and depreciated." His representative recorded him "crying and begging for the facility not to kick him out" during the discharge.
When the resident refused to leave, the facility called police to force his removal, treating him as a trespasser rather than addressing the underlying discharge process failures. This approach escalated an already traumatic situation and demonstrated insensitivity to the resident's legitimate concerns about the discharge.
Following the involuntary removal, the resident experienced housing instability, cycling between hospitals and homeless shelters. This disruption in stable housing likely exacerbated his existing mental health conditions and chronic pain management needs.
Industry Standards for Proper Discharge Planning
Appropriate discharge planning in nursing homes should be a collaborative process that prioritizes resident preferences and ensures continuity of care. The process typically involves comprehensive assessment of the resident's needs, identification of appropriate placement options, coordination with receiving facilities or services, and thorough preparation including medication reconciliation and education.
Discharge planning should begin early in a resident's stay and involve the interdisciplinary care team, the resident, and their representatives. When residents express preferences for specific types of housing - as this resident did regarding assisted living placement - facilities should make reasonable efforts to accommodate those preferences rather than forcing discharge to inappropriate settings like homeless shelters.
Federal oversight mechanisms including ombudsman notification exist specifically to prevent arbitrary discharges and ensure residents maintain access to advocacy services during vulnerable transitions.
Additional Issues Identified
The inspection revealed several other compliance concerns including failure to update care plans to reflect discharge planning changes, inadequate documentation of the discharge rationale in medical records, and lack of proper orientation and preparation procedures before discharge.
The facility's discharge policies contained appropriate language about resident rights and notification requirements, but implementation fell far short of these written standards. This gap between policy and practice suggests systemic issues with staff training and oversight of discharge procedures.
Administrative turnover may have contributed to the process failures, as the facility was operating with relatively new social services leadership during the time period in question. However, resident safety protections must remain consistent regardless of staffing changes.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for City Scape Rehabilitation & Care Center LLC from 2024-07-16 including all violations, facility responses, and corrective action plans.
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