Failure to Provide Required Discharge Notice and Notification to Ombudsman
Penalty
Summary
A resident with multiple complex medical conditions, including chronic respiratory failure, severe malnutrition, COPD, opioid dependence, and psychiatric disorders, was discharged from the facility without proper documentation or notification procedures being followed. The medical record lacked formal discharge documentation, and there was no physician note regarding the discharge. Staff interviews confirmed that the resident was discharged to the community without home health or oxygen services arranged, and the exact discharge location was unknown. The resident was not provided with a written discharge notice, nor was a 30-day notice given as required by facility policy. Further, the resident reported being told to leave the facility within 12 hours due to Medicaid payment issues, without being informed of her appeal rights or being given the opportunity to appeal the decision. The Ombudsman confirmed that no discharge notice was provided to their office, and the Medical Director was not involved in or aware of the discharge. Facility policy requires that written discharge notices be provided to the resident, their representative, and the Ombudsman, and that evidence of notification be maintained, but these steps were not followed in this case.