Failure to Provide Required Discharge Notice and Documentation
Penalty
Summary
A deficiency occurred when facility staff failed to provide an appropriate discharge for a resident with complex medical and behavioral needs. The resident, who had diagnoses including congestive heart failure, neurocognitive disorder with Lewy bodies, repeated falls, dementia, and was on hospice care, was transferred to a hospital following an incident of severe agitation and aggression. Staff attempted de-escalation techniques, but after the resident struck a staff member and exhibited exit-seeking behavior, the DON called 911 for a hospital transfer. The family was notified of the transfer for medical evaluation, but there was no clear communication that the resident would not be accepted back to the facility. The facility did not provide the required written notice of discharge, which should have included the date and location of discharge, a statement of appeal rights, and contact information for the State Long Term Care Ombudsman. Documentation of the bed hold policy was not found in the electronic records, and the family confirmed they did not receive a copy of the bed hold policy, notice of proposed transfer/discharge, or information regarding appeal rights. The resident's DPOA was not notified of the transfer or discharge, and there was no evidence of the resident or representative's involvement in the development of a discharge plan addressing the resident's needs. Interviews with facility staff revealed confusion and lack of coordination regarding the discharge process. The Social Services Director had little involvement and was notified after the transfer occurred, while the Admissions Coordinator was unaware that the resident would not return to the facility. The DON and LPN involved in the transfer did not communicate the final discharge decision to the family or DPOA. The hospital staff were also not informed that the resident would not be returning, and the hospital was not equipped to provide long-term care. As a result, the resident experienced confusion, physical and psychosocial harm due to the lack of appropriate planning and notification.