Failure to Provide Required Discharge Notification and Documentation
Penalty
Summary
The facility failed to provide the required written notification to a resident and their representative regarding discharge, omitting essential information such as the date and reason for discharge, the location to which the resident was being transferred, a statement of appeal rights, details about the appeal process, and contact information for the State Long-Term Care Ombudsman. Additionally, the facility did not send a copy of the discharge notice to the local Ombudsman office as required by policy. Record review showed that the discharge summary lacked documentation of discharge medications, follow-up appointments, the name of the continuing care physician, and summaries of care for physical and occupational therapy. The discharge summary also had blank sections for the Ombudsman’s contact information and resident/representative acknowledgment. Interviews with facility staff revealed that the Social Services Director provided the discharge notice to the resident only on the day of discharge and had not sent any notices to the Ombudsman office. The Director of Nursing confirmed that discharge planning should be incorporated into the resident’s care plan, but the required Nursing Home Transfer and Discharge Notice was not present in the record. The resident involved had multiple diagnoses, including multiple sclerosis, COPD, anxiety disorder, and depression, and required varying levels of assistance with activities of daily living. The facility’s failure to follow its own transfer and discharge policy resulted in the omission of critical notifications and documentation.