Failure to Provide Required Discharge Notification
Penalty
Summary
The facility failed to provide a written notice of discharge to a resident or their representative, as well as to the Office of the State Long Term Care Ombudsman, following the resident's discharge to home. The resident had been admitted with diagnoses including sepsis, type 2 diabetes mellitus, and inflammation of the hand, and was assessed to have intact cognitive function. Documentation in the electronic medical record included a discharge plan, but there was no evidence that the required discharge notification paperwork was given to the resident or sent to the Ombudsman. During the investigation, it was found that the facility could not produce the relevant transfer/discharge policy in effect at the time due to ownership changes. Interviews with facility leadership indicated that discharge planning and notifications were typically documented and provided, but in this case, there was no record of the required written notifications. The Ombudsman also confirmed not receiving any discharge notice for the resident. The facility administrator acknowledged the responsibility to notify both the resident's family and the Ombudsman, and noted that records should be retained and accessible, but was unsure of the specific retention period.