Failure to Provide Proper Notice and Planning for Facility-Initiated Discharges
Penalty
Summary
The facility failed to ensure that facility-initiated discharges were conducted in accordance with regulatory requirements for 13 of 14 residents reviewed. Specifically, the facility did not obtain physician orders for discharge, did not follow current discharge care plans, and failed to provide written 30-day notices of discharge to residents or their responsible parties. There was also a lack of documentation regarding discharge planning, resident-specific needs and services, and sufficient preparation or orientation to ensure safe and orderly transfers or discharges. These failures were identified through interviews and record reviews, which revealed that residents and their families were often unaware of the discharge until shortly before it occurred, and did not receive the required written notifications or explanations for the discharge. Multiple residents with complex medical histories, including diagnoses such as dementia, hemiplegia, diabetes, depression, and chronic obstructive pulmonary disease, were affected by these deficiencies. In several cases, residents expressed confusion, distress, and a lack of choice regarding their discharge, with some stating they were told to leave due to facility restructuring or remodeling. Family members and responsible parties also reported receiving little to no notice, inadequate communication, and no written documentation regarding the reason for discharge or available services. In some instances, residents were transferred to facilities far from their families, and there were reports of missing personal items and difficulties in obtaining medical records or medications after transfer. The facility's records did not consistently document whether the residents' needs could be met at the facility, the services available or unavailable, or the rationale for the discharge. There was also no evidence of discharge meetings or that residents or their representatives had requested the transfers. The lack of proper discharge planning and communication resulted in psychosocial harm, as residents experienced anxiety, sadness, anger, and disruption of their established living situations. The facility's actions did not align with regulatory requirements for safe and orderly discharges, as evidenced by the absence of required documentation and resident/family involvement.