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F0628
B

Incorrect Regulatory Citation on Involuntary Discharge Notice

Muscatine, Iowa Survey Completed on 08-07-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to cite the correct chapter of the Iowa Legislature State Regulations when issuing an involuntary discharge notice to a resident. The notice referenced Iowa Administrative Code 481-57.14(2), which applies to Resident Care Facilities, instead of the appropriate Chapter 58 for Long Term Care Facilities. This error was identified during a review of the clinical record, interviews with the long-term care ombudsman, and staff. The resident involved had an intact cognitive status, as indicated by a BIMS score of 15, and was dependent on staff for transfers. Diagnoses included paraplegia, anxiety, depression, and alcohol abuse with an alcohol-induced mood disorder. The involuntary discharge notice was hand-delivered to the resident, advising of discharge due to behavior posing a threat to the health and safety of others. The long-term care ombudsman confirmed that the incorrect code was cited and stated that the notice should have referenced the correct chapter. The ombudsman also noted that the error would typically render the notice inapplicable and require the process to be restarted. The deficiency was identified through the facility's documentation and interviews, which confirmed the use of the incorrect regulatory citation in the discharge process.

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