OIG: High Facility-Backed Discharges of Mentally Ill Residents From Nursing Homes ‘Raises Questions’ 

A majority of discharges of mentally ill patients from nursing homes are initiated by facilities due to dangerous behaviors, and perhaps many of these patients should never have been admitted in the first place given “the challenges” at nursing homes, according to the Office of Inspector General (OIG).

OIG’s review issued Wednesday suggests that of a sample of 126 residents at nursing homes, 72 were discharged due to behaviors that endangered them or others in a facility. And while the reasons for discharge fell under the approved list of reasons issued by federal authorities, the high number of such discharges raise concerns about the assessment process at nursing homes at the time of admission as well the information furnished by hospitals.

“Our review raises questions about whether nursing homes accurately assessed the behavioral health needs of residents upon admission, as well as whether nursing homes had the appropriate staff, resources, and capacity to care for residents,” OIG said. “Our findings highlight the challenges that nursing homes face in caring for residents with mental health disorders.”


The facility-initiated discharges from nursing homes were also due to receiving incomplete and inaccurate information from hospitals, leading to facilities being unprepared, the OIG review noted. Meanwhile, a lack of state-licensed mental health centers resulted in such patients being routed to nursing homes, which in turn were ill-equipped to handle them.

Facility-initiated discharges are defined by the Centers of Medicare & Medicaid Services (CMS) as those that take place despite not being requested by the resident, or go against the initial care plan.

“More research is needed into how to provide safe and effective long-term care for residents with mental health disorders and behaviors, especially as the demand for such care grows,” OIG said.


To counter this issue, the new Center for Excellence for Behavioral Health in Nursing Facilities, established by the Substance Abuse and Mental Health Services Administration in partnership with CMS, “holds promise,” OIG said.

In the OIG review, the majority of residents who were discharged from nursing homes due to endangering behaviors had been admitted to a nursing home with a mental health disorder, with 48 of the residents involved in physical and verbal aggression, including cursing fits and threats to staff.

The report cited the case of a resident being released from a facility because the nursing home lacked a locked and secure dementia unit, enabling the resident to exit through unsecured doors.

“We found that nursing homes discharged most of the 126 residents in our review due to endangering behaviors and aligned with 3 of the 6 allowed reasons for facility-initiated discharges,” the OIG review stated.

However, the federal oversight agency also noted that about two thirds of the residents with mental health disorders who were discharged due to behavior had been admitted for long-term care, suggesting that nursing homes were aware that these residents had mental health disorders upon admission and had expected to provide care for an extended period of time. Moreover, OIG’s nurse reviewers noted said many of these residents did not have a significant change in care needs that would prompt a discharge.

“Although nursing homes cannot anticipate all that a resident will need throughout a stay, nursing homes should be generally familiar with the demands of residents with mental health disorders, especially those who are admitted for long-term care.”

Before discharge, nursing homes tried changing medications and counseling as a common practice. And, most residents in OIG’s review were discharged to acute-care hospitals.

Other reasons for facility-initiated discharge included a failure to pay and improved health.

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