Failure to Provide Complete and Timely Discharge Notices and Notifications
Penalty
Summary
The facility failed to provide complete and timely discharge notices to resident representatives and did not notify the state health department of resident discharges, as required. This deficiency affected five residents who were discharged from the facility's secured memory care unit. Medical record reviews, interviews, and policy reviews revealed that discharge notices were missing critical information, such as the date and location of discharge, and did not include required details about appeal rights or advocacy contacts for residents with mental health disorders. In several cases, discharge notices were not sent with the initial letters, and when they were eventually sent, they were often incomplete or illegible due to poor copying quality. For each resident, documentation showed that representatives were informed of the memory care unit closure, but the written notices lacked essential elements. The discharge notices did not specify how to appeal the discharge, omitted the contact information for agencies responsible for the protection and advocacy of individuals with mental disorders, and failed to include the discharge order. Additionally, there was no evidence that revised notices with updated discharge dates and locations were sent to representatives once those details were determined. Certified mail receipts were inconsistent, and in some cases, there was no confirmation that the representatives received the required documentation. Interviews with the Social Service Designee and the Administrator confirmed that the state health department was not notified of the discharges, and the Ombudsman was not provided with the required discharge notices in a timely manner. The Ombudsman expressed concerns about improper discharges and the lack of appropriate notice, including the absence of information about appeal rights and discharge locations. The deficiency was further substantiated by interviews with resident representatives, who reported receiving incomplete or missing discharge documentation and insufficient assistance during the discharge process.