Failure to Provide Required Discharge Documentation and Notification
Penalty
Summary
The facility failed to provide all required documentation and notifications related to a resident's transfer and discharge. Specifically, there was no written notification of transfer provided to the resident or the resident's responsible party/power of attorney (RP/POA) prior to discharge. The responsible party reported not receiving any notification and expressed a desire to have time to search for alternative facilities and to tour the new facility before the transfer occurred. The facility staff confirmed that written notices were not provided in the resident's or responsible party's primary language, and there was no documentation in the medical record regarding the reason for the transfer. Additionally, the facility did not issue a 30-day written discharge notice to the resident, the responsible party, or the ombudsman prior to the discharge, as required. Interviews with staff revealed a misunderstanding of when 30-day discharge notices are necessary, with several staff members indicating that such notices were only given for non-payment situations. The ombudsman confirmed that no 30-day discharge notices had been received from the facility for recent transfers, and staff acknowledged that they did not routinely notify the ombudsman of all discharges. The resident involved had moderate intellectual disabilities, a developmental disorder of speech and language, and required assistance with personal care. The medical record and discharge summary lacked documentation of the reason for transfer, and staff could not provide evidence of whether the discharge was resident-initiated or facility-initiated. The facility's policy required documentation of discharge details and confirmation that the resident and/or responsible party understood the discharge plan, but this was not completed in this case.