Hyde Park Healthcare Center

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

independence while benefiting from convenient services, social opportunities, and a sense of community) to talk to me and told me that a room is available when I get discharged from the facility. Resident 1 stated

she informed the SS on 8/19/2025 about the available room and had requested to be discharged . Resident 1 stated the SS did not do anything for me to be discharged , and it made me anxious and sad. During an

interview on 8/21/2025 at 1:22 p.m. with the Activity Director (AD), the AD stated after the IDT meeting with Resident 1 on 8/19/25 at 10:30 a.m., Resident 1 verbalized that on 8/21/2025, she will be leaving the facility. The AD stated Resident 1 verbalized that she will sign AMA if nothing is prepared for discharge. The AD stated the SS explained Resident 1 about discharge process, but Resident 1 repeatedly stated that she will leave on Thursday, 8/21/2025. During an interview on 8/21/2025 at 3:43 p.m. with LVN 4, LVN 4 stated when Resident 1 expressed her wish to be discharged by Thursday 8/21/2025, the Director of Nursing (DON) was informed, but Resident 1's doctor was not called to obtain a discharge order. LVN 4 stated the facility failed to follow Resident 1's right to be discharged . LVN 4 stated, it caused Resident 1 to feel stressed and anxious because she felt the facility did not do anything for her request to be discharged . LVN 4 stated I should have called the doctor to get an order and start the discharge planning. During an

interview on 8/21/2025 at 2:17 p.m. with SS, the SS stated on 8/18/2025 the owner of an independent living facility came to the facility and spoke to Resident 1 about independent living. The SS stated the independent living facility had a room for Resident 1. The SS stated after the IDT meeting on 8/19/2025, LVN 4 was told to follow up with the doctor for a discharge order and with the treatment nurse regarding the wound condition before discharge. During an interview on 8/21/2025 at 4:00 p.m. with DON, the DON stated when the SS knew that Resident 1 had a bed available at the independent living facility, the nurse should have called the doctor and obtained the discharge order and informed the resident that they are working on her discharge. During a review of the facility's Policy and Procedures (P&P) titled, Transfer & Discharge, dated 12/2016, the P&P indicated when a resident is discharged , the facility should review the plan with the resident, and/or his or her family or responsible party, at least 24 hours before the resident's discharge from the facility. The P&P indicated to provide preparation and orientation to the resident to ensure safe and orderly transfer/discharge from the facility. The P&P indicated, if appropriate, to refer to the resident's discharge plan in their Comprehensive Plan of Care. The P&P indicated, preparation and orientation should include the following: informing the resident where he or she is going. taking steps to assure safe transportation. involving the resident and family in selecting the new residence. trial visits, if possible, by the resident to the new location. orienting the staff in the receiving facility to resident's daily patterns. reviewing with staff the routines for handling transfers and dischargesin a manner that minimizes unnecessary and avoidable anxiety ordepression. making appropriate referrals; and providing counseling, if necessary.The P&P indicated a discharge order should be obtained by nursing from the physician indicating where the resident is being discharged , why the resident is being discharged , reviewing with staff the routines for handling transfers and discharges in a manner that minimizes unnecessary and avoidable anxiety or depression in residents.

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