The resident was ready for discharge around November but couldn't get the required registered nurse assessment needed to set up home care because Social Services Coordinator #21 was out on leave. When the social worker returned, the RN assessment was completed, but the family was then told the facility had difficulty getting insurance clearance for home care.
The discharge delays had serious medical consequences. The resident was admitted with no open areas but developed a wound in November that healed and then reopened. When the resident left on an approved leave of absence with family, they still had an active wound.
While out on leave, the resident declined to return to the facility. Largo discharged them for failure to return, and no home care was ever set up. The wound became worse and infected, forcing the resident back to the hospital for admission.
The family's complaint to state inspectors revealed a pattern of communication breakdowns and missing documentation. "The assigned social worker repeatedly failed to return calls or follow through on discharge planning," the complaint stated. "After months of dishonesty and lack of communication, I confronted them in frustration. Since then, they have refused to speak with me and directed me to the administrator, leaving my family member without proper social work advocacy."
Social Services Coordinator #21 confirmed to inspectors that she was on leave from one date to another. Upon her return, she discovered the resident's Medicaid benefits had expired and refiled around early February. But when inspectors asked for documentation of the expired benefits timeframe and evidence of the renewal process, she couldn't produce any.
The social worker then told inspectors the resident was transferred to another facility social services coordinator upon her return. Again, no documentation of this transfer or the delays in communication with the resident and family were provided.
Inspectors reviewed the facility's electronic communication system used to discuss discharge readiness and home care needs with outside agencies. The entries showed a confusing timeline of missed connections and unclear delays.
One entry noted the resident's family was unable to be reached. Another showed the beneficiary was assessed. A level of care assessment needed to request home care was submitted, but the social worker couldn't explain to inspectors why the resident wasn't discharged at that point.
A final entry indicated the beneficiary was assessed and ready for discharge, but no discharge or home care readiness documentation was provided to support this conclusion.
When inspectors asked if there was any additional documentation given to the team indicating the resident was ready for discharge and home care was approved, Social Services Coordinator #21 stated "No."
The case illustrates how communication failures between nursing home staff and families can cascade into medical emergencies. The resident's wound, which had healed once during their stay, deteriorated to the point of infection requiring hospitalization after the botched discharge process left them without proper home care arrangements.
Federal regulations require nursing homes to provide proper documentation and notification related to residents' needs and discharge planning. The facility's inability to produce basic documentation about Medicaid renewals, care transfers between staff, or home care approval processes suggests systemic problems with record-keeping during critical discharge decisions.
The social worker's refusal to communicate with the family after being confronted about the delays left the resident without advocacy during a vulnerable transition period. By directing the family to speak only with the administrator, the social worker effectively abandoned her professional responsibility to coordinate the resident's care needs with outside agencies and family members.
The inspection found the facility failed to ensure proper discharge processes, affecting one resident investigated during the complaint survey. The case demonstrates how personal conflicts between staff and families can undermine patient care when professional responsibilities are abandoned in favor of avoiding difficult conversations.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Largo Nursing and Rehabiliation Center from 2025-11-03 including all violations, facility responses, and corrective action plans.
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