Failure to Provide Required Written Notification of Discharge to Guardian and Ombudsman
Penalty
Summary
The facility failed to provide timely and proper written notification to the State Guardian and the Office of the State Long-Term Care Ombudsman regarding its intention to discharge a resident, as required by federal regulations. The resident in question, who had diagnoses including dysphagia, schizophrenia, and bipolar disorder, was transferred to a Behavioral Health (BH) facility following combative and disruptive behavior, including physical aggression and property destruction. Documentation revealed that the facility did not notify the State Guardian or the Ombudsman in writing of the transfer or the subsequent decision not to readmit the resident, nor did it provide a 30-day written notice of discharge as required. The facility's own policies on transfer/discharge and bed hold did not address the required 30-day notice of transfer/discharge. Review of the resident's medical record and facility documentation showed inconsistencies and lack of clarity regarding who was notified, when, and how. The State Guardian and the Ombudsman both reported not receiving the required notifications, and the Guardian only learned of the facility's refusal to readmit the resident through the BH facility's Discharge Planner. Multiple attempts by the Guardian and the Discharge Planner to contact the facility for clarification went unanswered, and the Ombudsman was not informed of the discharge decision until after the fact. Interviews with facility staff, including the Business Office Manager, DON, and Administrator, confirmed that the required notifications were not sent in a timely manner or at all. The Administrator stated that a notice was not sent because the facility did not initially intend to refuse readmission, but later required documentation that the resident was not a danger before considering readmission. The lack of written notice and communication led to legal intervention, with the Guardian seeking a stay of discharge and legal counsel being retained. The Ombudsman and Guardian both confirmed that the facility did not follow required notification procedures, resulting in the resident remaining at the BH facility longer than necessary.