Failure to Provide Timely Discharge Notification and Required Documentation
Penalty
Summary
The facility failed to provide timely notification of discharge to a resident, their representative, and the ombudsman prior to or during the resident's transfer back to the hospital. Medical record review showed no documentation that the required discharge notice or care plan goals were sent to the hospital at the time of transfer. Additionally, there was no evidence that the education provided included a review of the specific information required to be sent to the receiving facility. The resident was transferred due to behavioral issues, including wandering, aggression, and combativeness, but had not been assessed by facility psychiatric services or a facility physician prior to the transfer. Interviews with facility staff and hospital personnel confirmed that the resident was sent back to the hospital without the necessary paperwork, belongings, or a bed hold notice. The DON made the decision to transfer the resident and communicated with the hospital, but the hospital social workers reported not receiving any documentation or notification of appeal rights. The facility hospital liaison and medical director were not directly involved in the decision or the transfer process, and the required notifications and documentation were not provided as mandated.