The resident was hospitalized two days later.
State inspectors found the facility failed to develop a safe discharge plan for the woman, identified as Resident CR1, who scored an 8 on a standardized cognitive assessment indicating moderate impairment. Physical therapy staff recommended she receive "significant supervision and assistance greater than 12 hours a day due to impaired cognition and safety."
She went home to live alone.
The resident was admitted to Grandview on December 10, 2024, with chronic kidney disease and traumatic brain injury. Her physician noted she "arrived at the facility fairly altered and confused" but "did well in therapy."
A December 17 progress note indicated the resident required 30 hours weekly of caregiver support. Physical therapy's discharge summary on December 26 recommended continued therapy services and extensive daily supervision due to her cognitive impairment and safety concerns.
The facility's interdisciplinary team discharge summary the same day made no mention of medication administration safety. It listed occupational and physical therapy home health services but provided no documentation of supervision availability upon discharge.
The resident left Grandview on December 27 with a medication list that included Insulin Glargine with instructions to inject 30 units subcutaneously once daily for diabetes.
Records show no evidence she received any training on safe self-medication during her stay.
"There was no plan in place to ensure Resident CR1 would be able to safely administer her medication upon discharge," the resident's representative told inspectors during a January 16 interview. The representative confirmed the woman lives alone and was admitted to the emergency department on December 29, "related to the need for continued care."
During interviews on January 15, the Director of Nursing and Director of Social Services confirmed the resident had moderate cognitive impairment. They could not provide documented evidence of self-medication training or education.
The Director of Social Services explained the resident was discharged with home nursing care, but medication administration was not included in the planned services.
"It is the facility's responsibility to ensure a safe discharge plan is developed and implemented for each resident," the Director of Nursing and Nursing Home Administrator confirmed during their interview with inspectors. They acknowledged the resident was hospitalized two days after discharge.
The facility's own assessment tools revealed the safety risks. The resident's Brief Interview for Mental Status score of 8 falls within the range indicating moderate cognitive impairment, affecting attention, orientation, and ability to register and recall new information.
Physical therapy staff explicitly documented their concerns about the resident's ability to function safely without extensive supervision. Their discharge summary recommended continued therapy "to maximize safe functional mobility" and noted the need for supervision exceeding 12 hours daily.
The interdisciplinary team's discharge planning ignored these recommendations.
Clinical records contained no documentation of the total supervision and assistance that would be available to the resident at home. The discharge summary failed to address medication safety despite the resident's cognitive impairment and complex medication regimen.
The Director of Nursing confirmed the discharge was not against medical advice, meaning facility staff approved sending the cognitively impaired resident home alone with medications she had never been trained to administer safely.
State inspectors cited the facility for failing to plan the resident's discharge to meet her goals and needs, finding minimal harm with potential for actual harm to few residents.
The resident's hospitalization within 48 hours of discharge demonstrated the consequences of inadequate discharge planning. Her representative's account revealed the gap between the facility's discharge summary and the reality of a brain-injured person attempting to manage complex medications without support.
The case highlights how nursing homes can discharge residents who appear stable in a supervised environment without ensuring they can safely manage their care independently. Physical therapy staff identified the resident's need for extensive daily supervision, but the discharge team proceeded without documenting how that supervision would be provided at home.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Grandview Nursing and Rehabilitation from 2025-01-15 including all violations, facility responses, and corrective action plans.
Additional Resources
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