Failure to Provide Required Discharge and Notification Documentation
Penalty
Summary
The facility failed to provide the required written notification of transfer or discharge to a resident, their representative, or the ombudsman, as mandated by both facility policy and state regulations. Specifically, a resident was discharged home without documented evidence that a 30-day written notice was given, nor was there documentation of the reasons for discharge, the effective date, or the discharge location in the medical record. Additionally, there was no evidence that a bed hold notice was provided, or that the ombudsman was notified at the time of discharge. The resident in question had diagnoses including anxiety disorder, COPD, depression, and polyosteoarthritis, and was assessed as having intact cognition but requiring significant assistance with most activities of daily living. Although a care plan meeting was held with the resident, family, and interdisciplinary team, and the resident requested an assessment from their Managed Long-Term Care (MLTC) provider for increased home care hours, there was no documentation that the MLTC was notified or that an assessment was scheduled prior to discharge. Progress notes did not reflect discussions about discharge planning or arrangements for post-discharge care, and the discharge documentation was incomplete regarding notifications to home care services. Interviews with facility staff revealed that while discharge planning discussions may have occurred verbally, required documentation was not completed. The discharge liaison and social worker both acknowledged that notifications and progress notes were not consistently documented, and the facility was unable to provide evidence of compliance with notification requirements when records were requested. This lack of documentation and notification represents a failure to meet regulatory requirements for resident discharge.