Valley Health: Patient Discharged Without Doctor Orders - MT
The Valley Health and Rehab sent the resident home on August 8 with only a notice to quit form signed two days earlier. No discharge summary, medication reconciliation, or care planning documentation existed in the resident's file.
The resident had moderate cognitive impairment with a score of 12 out of 15 on a federal assessment test. He required ongoing wound care and management of multiple medical conditions that had caused repeated hospitalizations before his nursing home stay.
Staff member A told inspectors on August 26 that the facility had no discharge orders or other discharge documentation besides the notice to quit. The resident had signed the notice on August 6, giving the facility two days to arrange his departure.
When inspectors asked about the missing documentation, physician NF5 acknowledged he could not locate a discharge order for the resident. NF5 said the practice was to obtain physician orders near the discharge date, including orders for home health services.
"There was a chance another provider wrote the physician order, but he could not find it at the time," NF5 told inspectors during an interview on August 27.
The physician described the resident as "a very sick person" who had experienced multiple rehospitalizations before arriving at the facility. NF5 said the resident had received home health support services for wound care and medical management before his nursing home stay and would have expected the facility to arrange these services again upon discharge.
Progress notes from July 15 through August 28 contained no evidence of discharge planning. The only entry related to discharge appeared in medication records, noting that ordered medications were not given after the resident left.
Staff member B provided inspectors with a single progress note and stated the physician was not notified of the resident's discharge until August 27 — nearly three weeks after the fact.
The resident's condition deteriorated rapidly after leaving the facility. NF5 told inspectors he was recently notified that the resident had been admitted to a local hospital. The physician had written an order to place the resident on hospice care due to his decline and osteomyelitis, a serious bone infection.
Federal regulations require nursing homes to obtain physician orders before discharging residents and complete comprehensive discharge summaries. The facility's own policy, updated in April, mandates that staff obtain physician orders for discharge and instructions for ongoing care.
The policy requires nurses to complete discharge summaries that include a recap of the resident's stay, diagnoses, treatment course, lab and radiology results, final status summary, medication reconciliation, and a post-discharge care plan developed with resident participation.
None of this documentation existed for the resident's departure.
The facility's admission and discharge report showed the resident had been admitted from a local hospital in late July and was listed as discharged home with home health services on August 8. But inspectors found no evidence that home health services were actually arranged or that any discharge planning occurred.
When inspectors requested all discharge communication and documentation from the resident's stay between July 15 and August 8, the facility provided nothing beyond the notice to quit form by the end of the federal survey.
The policy violation demonstrates a breakdown in basic patient safety protocols. The resident, already vulnerable due to cognitive impairment and serious medical conditions, was sent home without proper medical oversight or care coordination.
NF5 acknowledged the resident "was not the best at managing his health conditions" and "would have preferred being home." But federal law requires nursing homes to ensure safe transitions, particularly for residents with complex medical needs and cognitive limitations.
The inspection revealed actual harm to residents, with federal investigators citing the facility for failing to ensure each resident received adequate preparation and orientation for discharge or transfer. The violation affects the facility's overall safety rating and could trigger additional oversight.
The resident's rapid decline and hospitalization following discharge underscores the consequences of inadequate discharge planning. What should have been a coordinated transition home became an emergency admission to hospice care within weeks.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Valley Health and Rehab from 2025-08-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
THE VALLEY HEALTH AND REHAB in HAMILTON, MT was cited for violations during a health inspection on August 27, 2025.
The Valley Health and Rehab sent the resident home on August 8 with only a notice to quit form signed two days earlier.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.