Failure to Provide Written Discharge Notice and Documentation
Penalty
Summary
Facility staff failed to provide a resident with written notification of a pending discharge and did not ensure that the discharge was properly documented in the medical record. Record review showed that the resident was discharged, but there was no written notice of discharge, nor was there documentation of discussions with the resident regarding discharge planning, the resident's input, or the reason for discharge. The only documentation present was a progress note indicating the discharge had occurred. Interviews with staff revealed that while the social worker designee discussed discharge planning with the resident, who was uncertain about post-discharge arrangements, no written 30-day discharge notice was issued. The business office manager confirmed that the resident was only verbally informed of the discharge and given the option to appeal, which was described as the facility's standard practice when a resident's insurance was ending. The nursing home administrator acknowledged the concern during review.