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F0627
D

Failure to Provide Required Discharge Notice After Resident Transfer

Littlefork, Minnesota Survey Completed on 08-06-2025

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 provide the required notice of intent to discharge for a resident who was sent to the hospital and subsequently discharged from the facility. The resident, who had diagnoses including neurocognitive disorder with Lewy bodies, dementia with mood disturbance, agitation, and psychotic disturbance, was identified as having severe cognitive impairment and a risk for harm to self or others. The care plan included specific interventions for managing aggressive behavior and directed staff to contact law enforcement and send the resident to the emergency department if necessary. On the day of the incident, the resident physically assaulted another resident, leading staff to intervene and send the resident to the emergency department for further placement. Following the incident, the facility received notification that the hospital intended to return the resident, but the facility administrator instructed staff not to accept the resident back, citing a lack of resources to meet his needs. The resident was officially discharged and placed in a behavioral health unit. During an interview, the administrator confirmed the discharge was due to the resident's aggression and acknowledged that the facility did not provide the required notice of intent to discharge. The facility's discharge policy was requested but not provided.

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