Failure to Provide Required Discharge Notice to Resident and Ombudsman
Penalty
Summary
The facility failed to provide a required written notice of discharge to both the Ombudsman and a resident prior to the resident's discharge. Record review showed that the resident, who had diagnoses including generalized muscle weakness, dementia, and diabetes mellitus, was discharged to a lower level of care. The resident's Minimum Data Set indicated mild cognitive impairment and a need for varying levels of assistance with daily activities. Upon review of the closed record, there was no documentation of a discharge notice for the resident, nor evidence that the Ombudsman was notified. Interviews with the Medical Records Director and the DON confirmed that the notice of discharge was not present in the resident's record and had not been sent to the Ombudsman. Facility policy requires that residents and their representatives receive written notification of discharge, including specific information about the discharge, appeal rights, bed-hold policies, and contact information for advocacy agencies. The policy also mandates that a copy of the notice be sent to the Ombudsman at the same time as the resident and representative are notified. The absence of this documentation indicated noncompliance with facility policy and regulatory requirements.