Failure to Provide Required Transfer/Discharge Notice
Penalty
Summary
The facility failed to provide a written notice of transfer or discharge to both the resident and their representative, as well as to the ombudsman, for one resident. The resident, who had diagnoses including diabetes, quadriplegia, anxiety, and atrial fibrillation, was admitted to the facility and later experienced an unplanned discharge to the hospital, with no return anticipated. Review of the medical record and health status notes confirmed the transfer to the hospital, but there was no documentation that the required written notice was given. During interviews, both the Director of Nursing and Assistant Director of Nursing stated they were unaware of the requirement to send such notices and therefore did not provide or document them.
Plan Of Correction
F628 – Discharge Process Element #1: R#67 no longer resides in the community. Element #2: A full audit of discharges within the past 90 days was initiated by the Social Worker to ensure notification letters and documentation were completed. Any missing notifications were sent. Element #3: The Administrator reviewed the regulation F628 and updated the Discharge Checklist to include evidence of the mailed or emailed communication. Licensed Nurses and Social Work were educated on the guidelines for F628. Element #4: The Social Worker and/or designee will audit all discharges weekly for 12 weeks to confirm notice was provided to both the resident/representative and monthly to the Ombudsman. Results of the audits will be brought to the QAPI Committee monthly for review. Any changes to the auditing process will be determined by the QAPI Committee. The Administrator is responsible to attain and maintain compliance. Compliance Date: 6/20/2025