Failure to Provide Required Discharge Documentation
Penalty
Summary
Facility staff failed to provide the required documentation for the discharge of one resident. Specifically, the discharge notice issued to the resident did not include the effective date of discharge or the discharge destination, as required by facility policy. The notice did contain information about the reason for discharge, payment instructions, appeal resources, and ombudsman contact information, but omitted key details regarding when and where the resident would be discharged. There was also no evidence in the clinical record indicating the date the resident received the discharge notice. Interviews with staff revealed that the omission of the discharge date and location was intentional, as directed by a former administrator. The social worker involved confirmed that she was instructed to leave out certain information, including the final discharge location and the actual reason for discharge. The director of social services and the current administrator were not directly involved in the discharge process and could not provide further details. Facility policy requires that discharge notices include the effective date and specific location of discharge, and that any significant changes to the discharge plan be communicated with a new notice.