Failure to Provide Written Notice of Transfer/Discharge
Penalty
Summary
The facility failed to provide a written Notice of Transfer/Discharge to three residents and their responsible parties prior to their discharge, as required by both facility policy and federal regulations. Record reviews for three residents revealed that none had documented evidence of receiving the required written notice before being transferred or discharged to lower levels of care, such as assisted living or independent living facilities. Interviews with the Director of Nursing (DON) and the Social Service Director (SSD) confirmed that the notices were not provided, with the SSD citing being overwhelmed with workload as a reason for not issuing the notices in advance. The DON and a licensed nurse both acknowledged the importance of these notices in preparing residents and their families for discharge and reducing anxiety. The facility's own policies specify that a Notice of Proposed Transfer and Discharge must be given to the resident or their representative prior to discharge, with a copy placed in the medical record and sent to the Ombudsman. Despite these requirements, the review of clinical records and interviews with staff confirmed that the notices were not provided for the three residents in question. The absence of these notices meant that residents and their families were not formally informed in writing about the upcoming discharge, nor were they given the opportunity to appeal the decision, as required by regulation.