St. Teresa Nursing & Rehab Center gave Resident #1's responsible party a discharge notice on November 26, but federal inspectors found the facility had not developed any discharge plan for the patient, who was in a permanent vegetative state and required a tracheostomy.
The Business Office Manager told inspectors she had made several phone calls trying to reach the resident's responsible party but had not attempted any other means of contact. She said the facility had no information about what arrangements were being made to transfer someone requiring such intensive medical care.
The patient needed mechanical ventilation around the clock. A permanent vegetative state means the person shows no signs of awareness or purposeful response to their environment.
Federal regulations require nursing homes to complete discharge planning before issuing discharge notices. The process must assess continuing care needs, consider resident and family preferences, determine how services will be accessed, and coordinate care among multiple caregivers.
None of this happened for Resident #1.
The Business Office Manager said the facility was planning to file a complaint with Adult Protective Services for exploitation but was waiting until the last day of the 30-day discharge notice period to make the report.
During the December 19 inspection, LVN L MDS Nurse revealed that Social Worker T had quit without notice on December 11. The social worker had not written care plan conference notes for December 10 before leaving.
The LVN said the care plan contained no discharge plan. She did not know why the facility had failed to conduct the scheduled discharge planning orientation on December 5.
The facility's own policy, provided by the Administrator during the inspection, states that nursing facilities must complete discharge planning when anticipating discharge to a private residence, another nursing facility, or residential facility. The policy requires assessing continuing care needs, considering resident and family preferences, determining how services will be accessed, and coordinating care among caregivers.
The policy also mandates regular re-evaluations to identify changes requiring discharge plan modifications and assistance in locating and coordinating post-discharge services.
Federal inspectors found the facility violated discharge planning requirements that protect vulnerable residents from unsafe transfers. The violation carried a determination of minimal harm or potential for actual harm affecting few residents.
For a patient requiring mechanical ventilation and tracheostomy care, discharge planning becomes critical. These residents need specialized equipment, trained caregivers, and coordinated medical services. Without proper planning, such transfers can become life-threatening emergencies.
The inspection occurred December 19 in response to a complaint. The facility had issued the discharge notice nearly a month earlier but still had not completed basic planning requirements or established contact with the responsible party about transfer arrangements.
The case illustrates gaps that can emerge when key staff members leave without notice. Social Worker T's sudden departure on December 11 left care plan documentation incomplete and discharge planning responsibilities unclear.
The Business Office Manager's plan to wait until the final day of the discharge notice period before filing an Adult Protective Services report raised additional concerns about the facility's approach to resident protection and family communication.
Federal regulations exist specifically to prevent nursing homes from discharging medically complex residents without ensuring appropriate receiving care arrangements. The requirements become especially important for residents in permanent vegetative states who cannot advocate for themselves or communicate their needs.
Resident #1 remained at St. Teresa Nursing during the inspection, still without a completed discharge plan despite the November 26 notice. The facility had spent weeks unable to contact the responsible party while a ventilator-dependent patient in a permanent vegetative state faced an uncertain transfer situation.
The violation demonstrates how administrative failures can compound into serious resident safety risks, particularly when facilities attempt to discharge patients requiring intensive medical support without proper coordination or family communication.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for St. Teresa Nursing & Rehab Center from 2025-12-19 including all violations, facility responses, and corrective action plans.
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