Facing increased fiscal and liability pressures, more US nursing homes are initiating involuntary patient discharges.
AARP this week reported that complaints about what it called evictions had increased nationwide, with the National Ombudsman Reporting System seeing an 8.6% increase from 2023 to 2024.
In an article advising consumers how to fight “unjust” discharges, the consumer organization paints nursing homes as eager to move out needy residents. It urges family caregivers to work with a local long-term care ombudsman to appeal and spot “illegal violations.”
But most nursing homes are simply acting within their rights and almost always in accordance with specific circumstances allowed by the Centers for Medicare & Medicaid Services, said attorney Adam Guetzow, chair of Hinshaw’s national Health Care Practice Group.
Guetzow said he most often sees facilities use an involuntary discharge as a final resolution in cases where they need to protect residents — in the case of safety concerns — or ensure that patients unwilling to pay for their care don’t push facilities into insolvency.
An Office of Inspector General report published last year validated that, calling resident behavior the top reason for skilled nursing discharges.
“There has been an increase in the mental health population within SNFs, and with that comes, oftentimes, resident-on-resident altercations. A SNF can only do so much,” Guetzow told McKnight’s Long-Term Care News Wednesday. “What I find happening is you have a resident that perhaps may have some additional mental health needs and they are having increasing behavioral issues, and they may be impacting the safety of other residents. We can redirect, care plan, do what the SNF needs to do, but if that’s not working, the issue becomes the larger safety of all of the residents in the community versus that one resident.”
Changing times
Guetzow said diagnoses becoming common in nursing homes today used to be more commonly treated in specialized facilities for mental health; they can require intense or escalating interventions that SNFs may or may not be able to provide. It’s often a patient in crisis, or one refusing treatment, that receives a discharge notice.
“If a resident abuses another resident, they [the SNF] get cited for abuse on a regulatory survey. They need to make sure that the person is not injuring other people,” Geutzow added. “And if they can’t get control of it despite proper interventions being put in place, an IVD is the appropriate result.”
Another frequent issue cited in involuntary discharges Guetzow sees is a resident’s lack of payment.
“Nursing homes are running in a very tough market,” he said. “They don’t want to have to carry the bill for someone if they don’t have to, and to the extent that someone’s not paying their private pay or they’re not cooperating to get on to Medicaid, it may be that long-term care facilities aren’t able to foot the bill anymore.”
AARP in its latest article on discharges concedes both non-payment and the safety of other reasons are accepted reasons provided by regulators for involuntary discharges.
Others allowed reasons for discharge are when:
- The nursing home cannot meet the resident’s medical needs
- The resident’s health improves to the point that they no longer require long-term care
- The resident’s presence or behavior endangers the health of other residents
- The facility is closing permanently
AARP also noted that involuntary discharges have increased since the COVID-19 pandemic, citing statistics from California (where notices rose from 195 in 2022 to 273 in 2024) and Michigan (where notices were up to 317 in 2024, from 143 in 2022).
Satisfying regulators
And it’s not just consumer advocacy groups that are watching. CMS itself is putting more pressure on nursing homes to prevent involuntary discharges, or at least to toe the line very carefully.
Earlier this year, the agency updated its guidance to surveyors tasked with ensuring discharge compliance. They are instructed to contact an ombudsman before a survey begins to ask about complaints related to inappropriate discharges.
And they’ve been instructed to look for evidence of noncompliance, including whether evidence in the medical record supports a basis for discharge. In a discharge based on an inability to meet the resident’s needs, for instance, CMS says the nursing home must present evidence that it attempted to meet the resident’s needs and include an assessment indicating exactly which needs cannot be met.
In the case of failure to pay, surveyors may be able to cite nursing homes if there is no evidence the facility offered the resident to pay privately or apply for Medical Assistance, or that the resident refused to pay or have paid under Medicare or Medicaid.
When it comes to protecting the safety of a patient or other residents, Guetzow added, providers must show they’ve exhausted all remedies available at the facility.
“That means care planning, redirection, making sure that your staff is aware of interventions they can put in place and making sure they’re monitoring appropriately,” he said. ”It’s also properly documenting the instances that have occurred as a result of that individual not following the directions you put in place for them and their needs.”
Guetzow emphasized that no discharge can take place if a resident has appealed and an appeal is pending. State and federal guidelines also dictate how many days’ notice residents must receive, as well as what assistance providers must give residents or their families as they leave the facility.
For patients with behavioral health concerns, Guetzow also recommended a “cooperative discussion” with the public health department so it’s aware of the termination of residency and can support a transition.
Kimberly Marselas. (2025, November 20). As pressures mount, so do involuntary nursing home discharges. Here’s how providers should approach them. https://www.mcknights.com/news/as-pressures-mount-so-do-involuntary-nursing-home-discharges-heres-how-providers-should-approach-them/
