Brookhaven Nursing and Rehabilitation Center sent Resident#1 to an acute behavioral hospital on October 3, 2025, but failed to follow federal protocols requiring comprehensive medical documentation accompany transferred patients.
The geriatric social worker at the behavioral hospital told inspectors during a November 4 interview that her facility was designed for short-term stabilization to establish medication regimens, not long-term placement. She emphasized that no clinical discharge summary was provided with the transfer.
Multiple staff members acknowledged the facility's failure to complete required documentation.
LVN A, the nurse on duty during the transfer, admitted she did not complete a discharge summary or the facility's E-interact system — dashboard checklists designed to reduce acute care transfers. "It was a busy day," she told inspectors. She acknowledged that failure to provide discharge summaries to admitting facilities "could result in the residents not receiving the care they deserve."
The facility's physician said he called the emergency room and spoke with the ER doctor and case management staff, notifying them the resident would not return. But he did not create a discharge summary, stating "the nurse was responsible for the discharge summary."
SW B, a social worker, said she did not send clinical documents or complete a discharge summary because "the former Administrator and the DON oversaw the transfer." She told inspectors it was "important to provide the admitting facility with proper documentation such as clinical discharge summary so the residents can be cared for appropriately."
The Director of Nursing, employed for only one month, could not locate any documentation from the October 3 transfer date. She told inspectors that during the last week of October, an email indicated SW C had obtained everything needed to find Resident#1 a new facility. She acknowledged it was "necessary to provide clinical discharge summary to the receiving hospital for continuum of care."
The newly hired administrator said he was not involved in the discharge and could not explain how it was overseen. He told inspectors that "even in an immediate transfer there is procedure and protocol to ensure the receiving facility had enough information to care for the resident."
He said his expectation was "there would be a time and record of when the resident signed and accepted the discharge notice."
The facility's own Transfer or Discharge Emergency policy, last revised in August 2018, requires specific procedures for emergency transfers. The policy mandates staff notify the resident's attending physician, notify the receiving facility, prepare the resident for transfer, prepare a transfer form to send with the resident, notify family members, and assist in obtaining transportation.
The policy specifically states that "the resident's medical record must be forwarded to the Medical Records office within twenty-four hours of the transfer or discharge."
None of these required steps appeared to have been documented or completed according to the inspection findings.
The case highlights a breakdown in communication and documentation protocols that multiple staff members recognized as problematic. Each interviewed employee understood the importance of proper discharge documentation, yet no one ensured it was completed.
The behavioral hospital's social worker explained that her facility needed comprehensive medical information to properly evaluate and establish medication regimens for transferred patients. Without clinical discharge summaries, receiving facilities cannot provide appropriate continuity of care.
The inspection occurred as a result of a complaint, suggesting concerns about the facility's transfer procedures had been raised externally.
Federal regulations require nursing homes to ensure proper documentation accompanies all transferred residents to protect patient safety and care quality. The failure to provide required medical records during transfers can compromise patient outcomes and violate residents' rights to appropriate care.
Resident#1's transfer to the behavioral hospital was intended to stabilize his behavior through medication management. However, without proper clinical documentation from Brookhaven, the receiving facility lacked essential information about his medical history, current treatments, and care needs.
The inspection revealed a facility where newly hired leadership inherited problems from previous management, but current staff still failed to follow established protocols designed to protect resident welfare during transfers.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Brookhaven Nursing and Rehabilitation Center from 2025-11-04 including all violations, facility responses, and corrective action plans.
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