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F0628
D

Failure to Provide Required Written Discharge Notice and Appeal Rights

Stockton, California Survey Completed on 06-02-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide a required written discharge notice to a resident, the resident's representative, and the Office of the Long-Term Care Ombudsman prior to a planned discharge. The resident, who had a history of cerebral infarction, muscle weakness, gait abnormalities, dysphagia, major depressive disorder, and anxiety disorder, was scheduled for discharge to home with support following the cessation of skilled services. Although the discharge disposition was discussed verbally with the resident's daughter and referrals for post-discharge support were made, no formal written notice of discharge was given to the resident, her representative, or the Ombudsman as required by regulation. Interviews revealed that the Social Services Director acknowledged the lack of a formal discharge notice, stating that it was not provided because the discharge was still pending. Both the resident and her family member confirmed that they were verbally informed of the impending discharge about a week in advance, but did not receive the required written notice. The family member appealed the discharge, and the Ombudsman was involved after being contacted by the family. The Ombudsman also confirmed that no written notice was received and that the resident was anxious due to the discharge process and lack of communication. Facility policy requires documentation of transfer or discharge and communication with the receiving provider, as well as preparation of the resident in advance. Federal and state regulations mandate that written notice be provided to the resident, their representative, and the Ombudsman at least 30 days in advance, or as soon as practicable, with an opportunity to appeal. In this case, the absence of a written notice removed the opportunity for timely advocacy and appeal, and resulted in confusion and distress for the resident and her family.

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