Failure to Provide Proper Discharge Notice and Notification to Ombudsman
Penalty
Summary
The facility failed to provide a 30-day advance written notice of discharge to a resident, as required by both federal and state regulations. The resident, who had diagnoses including acute respiratory failure, influenza, and pneumonia, was verbally informed of the discharge on the same day the facility attempted to discharge him and received the discharge paperwork at that time. There was no evidence that the resident received any prior written notification about the impending discharge before that day, despite the facility's policy and regulatory requirements for advance notice. Additionally, the facility did not send a copy of the Notice of Transfer or Discharge to the Ombudsman's office on the same day the resident was served the notice. The resident contacted the Ombudsman independently and was informed that their office had not received the required notice from the facility. Interviews with facility staff confirmed that the notice was not sent to the Ombudsman, and there was a misunderstanding among staff regarding the timing and necessity of this notification, particularly for residents with Medi-Cal coverage. Furthermore, there was a discrepancy between the discharge location listed on the resident's Notice of Transfer or Discharge and the location specified in the physician's discharge order. The notice indicated one homeless shelter, while the physician's order specified a different shelter. Facility staff, including the Social Services Director, Case Manager, and ADON, acknowledged that the discharge locations should have matched and confirmed the inconsistency. The facility's own policy requires that the specific discharge location be accurately documented and communicated.