Failure to Provide Required Discharge Notice Prior to Resident Discharge
Penalty
Summary
A deficiency occurred when the facility failed to provide a required discharge notice to a resident prior to discharge. The resident, who had a history of chronic obstructive pulmonary disease, lung cancer, opioid dependence, anxiety disorder, hypertension, depression, and a recent encounter following alleged adult physical abuse, was initially admitted and later issued a 30-day discharge notice due to noncompliance with facility rules and a behavior contract. Despite the notice, the resident remained in the facility past the stated discharge period. Subsequent documentation showed the resident exhibited ongoing behavioral issues, including threatening staff and other residents, possession of alcohol, and manic behaviors, which led to police involvement and a physician's order for psychiatric evaluation and hospital transfer. After the resident was transferred to the hospital and not permitted to return, there was no evidence in the medical record or facility documentation that a discharge notice was provided at that time. Interviews with the DON and Social Services Designee confirmed that no discharge notice was issued once the decision was made to not allow the resident to return. Facility policy required that a discharge notice be provided to the resident and their representative prior to discharge, but this was not followed in this case.