Failure to Provide Required 30-Day Discharge Notice and Proper Discharge Planning
Penalty
Summary
A deficiency was identified when a resident was discharged from the facility without receiving the required 30-day advance discharge notice. The resident, who had a documented history of certain diagnoses and a Brief Interview of Mental Status (BIMS) score, was involved in an incident with a roommate. Following this incident, the resident did not return to the facility, and staff communicated the discharge to the resident's responsible party via phone call. There was no evidence in the record that the required written notification was provided to the resident or their representative. Interviews with facility staff, including two social workers and another staff member, revealed that the decision to not readmit the resident was made by administration and admissions, not by the social workers. Staff described the discharge as 'safe' because the resident had nowhere else to go and because medications and the electronic Medication Administration Record (eMAR) were provided to the responsible party upon the resident's departure. However, there was no documentation of a formal discharge process or orientation to ensure a safe and orderly transition, as required by regulations. Record review confirmed the absence of documentation for a 30-day advance discharge notice or evidence of a comprehensive discharge plan. The facility failed to comply with federal and state requirements regarding transfer and discharge, including the need for proper documentation, communication, and preparation for discharge. The lack of adherence to these procedures resulted in the resident being discharged without the protections and planning mandated by regulation.
Plan Of Correction
F 627 F627 Inappropriate Discharge ELEMENT 1 The Director of Nursing reviewed the discharge documentation of Resident #16 and clarified the actions taken by Resident #16 regarding the disposition of the resident. A clarifying note was also placed in the chart of Resident #16 regarding the actions taken by NJ Ex Order 26.4(b)(1). Per the direction of NJ Ex Order 26.4(b)(1), all needed physician orders and medications were provided to NJ Ex Order 26.4(d)(1). Who Nex order 26.4(b)(1) Resident #16 into their custody and placed the resident in a safe location with medical staff available to provide care. The family and physician were notified of the NJ Ex Order 26.4(b)(1) actions. Social work and all nursing staff received re-education about 30-day notice of discharge and safe discharge. ELEMENT 2 All residents have the potential to be affected by this practice. ELEMENT 3 The policy for discharge when necessary was reviewed and updated as appropriate by the Licensed Nursing Home Administrator and Director of Nursing. The Director of Nursing re-educated leadership on documentation of discharge when necessary. Discharges occurring from January 2025 through May 2025 were audited to ensure that there were no other occurrences of discharge when necessary. The documentation of Resident #16 and clarified the actions taken by Resident #16 regarding the disposition of the resident. A clarifying note was also placed in the chart of Resident #16 regarding the actions taken by NJ Ex Order 26.4(b)(1). Per the direction of NJ Ex Order 26.4(b)(1), all needed physician orders and medications were provided to NJ Ex Order 26.4(d)(1). Who Nex order 26.4(b)(1) Resident #16 into their custody and placed the resident in a safe location with medical staff available to provide care. The family and physician were notified of the NJ Ex Order 26.4(b)(1) actions. Social work and all nursing staff received re-education about 30-day notice of discharge and safe discharge. ELEMENT 4 A root cause analysis was conducted and a QAPI performance improvement project team formed to address discharge concerns. The Social Worker reports on discharges monthly. Findings shall be reported to the Licensed Nursing Home Administrator weekly for three months. The findings and actions taken will be reported to the QAPI committee for review and further direction as appropriate. Date of Completion: June 9, 2025