Deerings Nursing and Rehabilitation discharged a resident to another facility without issuing the required 30-day notice, conducting discharge planning meetings, or notifying the state ombudsman, according to a November complaint inspection by federal regulators.
The resident agreed to transfer voluntarily after the previous administrator told him about a Houston facility that would accept him. But federal law requires specific protections even when residents consent to discharge.
"The resident had agreed to go on his own will thus reason there was no 30-day notice given," the previous director of nursing told inspectors during a November 10 phone interview. She said she was present when the administrator offered the Houston option to the resident.
Nobody could locate discharge documentation. The current resident care coordinator searched the resident's file and found no signed discharge papers. "The RCN said whenever there was a discharge it had to be signed by the doctor and none of that was found," inspectors wrote.
Staff believed the resident simply left on his own rather than being formally discharged. The resident care coordinator told inspectors he thought "Resident #1 might have left the facility on his own will and was not necessarily discharged by the facility so no 30-day notice was issued."
But staff acknowledged they should have contacted the ombudsman regardless. The previous director of nursing said she "did not recall if the Ombudsman was notified of the discharge."
No discharge planning meeting occurred before the transfer. The previous director of nursing confirmed to inspectors "they had not had a discharge plan meeting before the resident was discharged."
LVN A described the resident as eager to leave. "Resident #1 willingly left the facility and that he was happy to leave the facility and start in a new place," the nurse told inspectors during a 3:00 pm phone interview.
The only family contact involved reaching the resident's family member about the move. "At first she was kind of not sure but then later she was okay with the move," LVN A said. "As far as he knew that was the only discharge plan that was done."
LVN A recalled the resident signing some document but couldn't identify what. "He did remember the resident signing a form but it could have been the list of medications he was taking with him."
The current interim administrator, who wasn't at the facility during the discharge, said proper procedures should have been followed. "The facility should have followed their policy on how to perform a safe discharge so that the resident could receive the best care when discharged to another facility."
The facility's own discharge planning policy requires extensive protections. Nursing facilities must complete discharge planning when moving residents to private residences, assisted living, other nursing facilities, or residential locations.
The policy mandates assessing continuing care needs and considering resident and family preferences. It requires developing interdisciplinary team discharge plans "designed to ensure that the residents needs will be met after discharge from the facility."
Facilities must maintain collaboration with local contact agencies and assist residents in "locating and coordinating post discharge services." The policy requires discharge summaries including diagnoses, treatment course, lab results, and post-discharge care plans.
The discharge summary "will help the resident adjust to their new living environment" and must be filed in the medical record, according to facility policy.
None of these protections occurred for the Houston transfer. No interdisciplinary team met. No discharge summary was prepared. No collaboration with agencies happened. No assessment of continuing care needs was documented.
Federal discharge requirements exist because vulnerable nursing home residents need protection during facility transfers. Even voluntary discharges require safeguards to ensure residents receive appropriate continuing care and aren't abandoned without proper planning.
The violation received minimal harm designation, affecting few residents. But the case illustrates how facilities can circumvent federal protections by treating voluntary departures as informal exits rather than formal discharges requiring regulatory compliance.
The resident who moved to Houston left without the comprehensive discharge planning, medical documentation, and care coordination that federal law requires to protect nursing home residents during facility transfers.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Deerings Nursing and Rehabilitation, Lp from 2025-11-10 including all violations, facility responses, and corrective action plans.
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