Failure to Notify Resident's Representative of Discharge Decision
Penalty
Summary
The facility failed to notify a resident's representative or family member of the intent to discharge, as required by facility policy. The policy states that in the event of an emergency transfer or discharge, the representative or family member must be notified. In this case, a resident with severe cognitive impairment, as indicated by a BIMS score of 8, was discharged to a psychiatric care facility. Documentation in the medical record showed the resident was transported in stable condition, and the receiving facility communicated that the resident could not return due to elopement risk and the need for a secure unit. Despite these events, the resident's representative confirmed during an interview that she was unaware of the facility's decision to discharge and the refusal to accept the resident back. Both the Social Services Director and the Director of Nursing acknowledged that Social Services was responsible for informing the representative and that this communication should have been documented in the medical record. The lack of notification and documentation constituted a failure to follow the facility's discharge procedures.