Failure to Notify Resident's Representative of Discharge Planning
Penalty
Summary
The facility failed to notify a resident's legal representative of discharge planning, orders, and arrangements for post-discharge care. The resident, who was cognitively intact and had multiple medical diagnoses including anemia, COPD, heart failure, substance abuse, and anxiety disorder, had been under state guardianship since 2022. Despite this, the state guardian was not informed of the resident's discharge or the details of the discharge planning. The guardian only learned of the discharge after sending an associate to visit the resident and did not receive any court documentation regarding the revocation of guardianship. Interviews with facility staff, including the Social Service Director and the Director of Nursing, confirmed that the guardian was not notified prior to the discharge. The Social Service Director admitted to not informing the guardian and acknowledged this was a mistake. Facility policy requires notification of the resident's representative regarding discharge planning, but there was no documentation in the resident's records indicating that such notification occurred.