Failure to Complete Timely and Thorough Discharge Process
Penalty
Summary
The facility failed to complete a requested discharge process in a timely and thorough manner for one resident. The resident, who had multiple medical diagnoses including muscle wasting, cognitive communication deficit, traumatic subdural hemorrhage, and several chronic conditions, was cognitively intact at the time of the incident. The resident and/or their power of attorney (POA) requested referrals to two different nursing homes for transfer, and both referrals were submitted but subsequently denied. After these initial attempts, there was no further documentation or evidence that the facility pursued additional transfer or discharge options for the resident. Interviews and record reviews confirmed that after the two denied referrals, the facility did not follow up with the resident or the POA to verify continued interest in transfer or to assist in identifying other placement options. The administrator acknowledged that no further efforts were made and that there was no documentation of follow-up conversations or actions taken regarding the discharge request, aside from a single attestation written weeks later. This lack of action and documentation was inconsistent with the facility's own resident rights policy, which requires support for residents in exercising their rights, including communication and access to services both inside and outside the facility.