Failure to Document and Notify Required Parties During Resident Discharge
Penalty
Summary
The facility failed to properly document and implement an effective discharge plan for one resident who was reviewed for discharge planning. Specifically, the facility did not ensure that the discharge planning process was documented in the resident's electronic medical record (EMR), including the reason for discharge. The resident, who was cognitively impaired with a BIMS score of five out of 15 and had diagnoses including anoxic brain injury, alcohol dependence, chronic pancreatitis, and accidental opioid poisoning, was discharged to another skilled nursing facility. The care plan and assessments did not reflect active discharge planning or the resident's need for a facility that accommodated smoking, which was a factor in the discharge. The facility also failed to provide written notification to the resident and the resident's representative regarding the discharge. The letter sent to the representative did not include required information such as the reason for discharge, the effective date, the location of discharge, a statement of appeal rights, or the contact information for the state long term care ombudsman. There was no evidence in the EMR that the resident or representative received proper written notification after the initial letter, nor was there documentation that the ombudsman was notified in writing about the discharge. Interviews with facility staff confirmed these deficiencies. The social services director acknowledged that the required information was not included in the letter to the representative and that no letter was sent to the ombudsman. The nursing home administrator also confirmed that the necessary written notifications were not provided to the resident, the representative, or the ombudsman. Additionally, a frequent visitor with knowledge of the facility and the resident was unaware of the discharge and had not received any written or electronic notification.