Failure to Provide Required Discharge Notice and Documentation
Penalty
Summary
The facility failed to permit a resident to remain in the facility and did not document the reason or provide notice of discharge in the resident's medical record. The resident, a male with diagnoses including metabolic encephalopathy, gastric reflux, prostate disease, Parkinson's disease, and cognitive communication deficit, was sent to the emergency room for evaluation after exhibiting out-of-character behavior involving an incident with a staff member. Despite the hospital finding no medical changes and clearing the resident for return, the facility refused to accept him back and did not provide the required written discharge notice to the resident, his representative, or the Long-term Care Ombudsman. Interviews with facility staff confirmed that the normal process is to issue a 30-day discharge notice and assist with safe discharge planning, but this was not followed in the resident's case. The resident's chart did not contain a discharge notice, and discharge paperwork was still in process after the resident was denied re-admission. The facility's own policy requires written notification and documentation of discharge at least 30 days in advance, which was not adhered to in this instance.