Failure to Provide Required Discharge Notices and Ombudsman Notification
Penalty
Summary
The facility failed to provide the required written 30-day notice of discharge, bed hold policy, discharge summary, and the reason for discharge to the resident's court-appointed guardian. Additionally, the facility did not provide a statement of appeal rights, nor did it include the name, address, or telephone number of the Office of the State Long Term Care Ombudsman. The Ombudsman was also not notified of the resident's discharge. The facility was unable to provide its Discharge Policy upon request. The resident involved had multiple diagnoses, including major depressive disorder, diabetes, pulmonary disease, traumatic brain injury, Parkinson's disease, anxiety disorder, and paranoid schizophrenia. The care plan indicated the resident and guardian wished for long-term placement at the facility, and the resident had a history of psychiatric hospitalizations. On one occasion, the resident was transferred to an emergency room following a suicide hotline call, but there was no documentation of a bed hold notice, appeal rights, or Ombudsman contact information related to this transfer. The guardian did not receive discharge instructions, a recapitulation of the resident's stay, a final summary status, or a reconciliation of medications. Communication records show that the facility decided not to allow the resident to return after a psychiatric hospitalization, citing an inability to provide the necessary level of safety. The guardian was informed of this decision and agreed to a transfer to another skilled nursing facility only after being told the resident could not return. Interviews with facility staff and the guardian revealed conflicting accounts regarding the resident's wishes and the discharge process, but it was confirmed that the required written notifications and documentation were not provided to the guardian, and the Ombudsman was not notified.