Deficient Involuntary Discharge Notice and Documentation
Penalty
Summary
The facility failed to ensure that the involuntary discharge notice provided to a resident or their representative included all required information. Specifically, the notice did not contain a statement of appeal rights, the location to which the resident would be discharged, or the contact information for the required state agencies. Additionally, the notice did not provide instructions on how to initiate or submit an appeal. The letter did include contact information for the long-term care ombudsman and a list of local LTC facilities, but omitted other regulatory requirements. The notice was issued due to non-payment of services, with documentation indicating the resident had been denied Medicaid services for failure to submit required paperwork. Further review revealed that the resident's electronic health record did not contain a physician order to discharge, although a scanned order was present in the resident documents. The facility's policy on admission, transfer, and discharge referenced compliance with regulations and documentation of the reason for discharge in the clinical record, but did not address providing a written discharge summary, recapitulation of stay, or medication reconciliation to the resident or their representative. The resident involved had significant medical needs, including respiratory failure with hypoxia, hypothyroidism, weakness, and required assistance with personal care.