Failure to Provide Written Discharge Notice
Penalty
Summary
The facility failed to provide a written notice of discharge for one resident who was reviewed for transfer and discharge requirements. According to the facility's policy, a written notice of transfer or discharge must be given 30 days prior to the event unless there is an immediate threat to health or safety. Record review and staff interviews confirmed that no written discharge notice was provided to the resident at the time of discharge. The Social Service Director acknowledged that a written notice was not given. The resident involved was cognitively intact, able to make her own decisions, and required moderate assistance with activities of daily living. She had ongoing and active substance use, including nicotine, methamphetamines, and methadone, which led to complex and unstable medical conditions. The resident exhibited behaviors such as leaving the facility and returning in a compromised state, declining care, and inconsistent eating, resulting in medical interventions for diabetes-related events. The facility determined that her needs exceeded their capacity and arranged for her transfer to a hospital, after which she was not readmitted. The lack of written discharge notice was confirmed through interviews with facility staff and collateral contacts.