Failure to Provide 30-Day Discharge Notice and Adequate Discharge Planning
Penalty
Summary
The facility failed to provide a 30-day discharge notice and appropriate discharge planning for a resident who was being discharged. The resident, who had diagnoses including morbid obesity, difficulty in walking, and epilepsy, was admitted from a hotel and was unable to return there due to eviction. The resident was cognitively intact and had no family involvement. During a care conference, it was noted that the resident was homeless and unable to secure alternative housing. The facility determined that the resident no longer required skilled nursing care or therapy and issued a Notice of Adverse Decision, denying continued stay. Social services assisted the resident in finding a hotel room and made arrangements for a primary care provider appointment and home health referral. However, there was no evidence in the medical record that a 30-day discharge notice was provided, that the Ombudsman was notified or involved in the discharge process, or that the resident was assisted in securing safe housing beyond the hotel arrangement. The resident was discharged to a hotel, and documentation did not confirm the resident's agreement to this discharge plan. Interviews with facility staff confirmed that the resident did not want to pay for continued stay and chose to be discharged to a hotel, but the Ombudsman was not notified, and there was no documentation of coordination with the Ombudsman or evidence of comprehensive discharge planning. The facility's policy required notification of the Ombudsman and a post-discharge plan of care, but these steps were not documented or completed for this resident.