Failure to Provide Required Discharge Planning and Notification
Penalty
Summary
The facility failed to follow its own Discharge Planning Process policy for a resident by not initiating a discharge care plan upon admission, not providing a completed Discharge Transition Plan prior to discharge, and not giving the required Notice of Transfer or Discharge form to the resident before discharge. The resident was admitted with multiple diagnoses, including muscle weakness, polyneuropathy, and fractures, and was assessed as having intact cognitive function and the ability to make decisions. Despite this, the care plan did not include a discharge plan from the time of admission, and the Discharge Plan Documentation form was not completed before the resident left the facility. Interviews and record reviews revealed that the resident was approached by a nurse with a blank Notice of Transfer or Discharge form and requested to sign it. The resident declined to sign until she could review the completed form, but the nurse did not return with it. After discharge, the resident found a signed Notice of Transfer or Discharge form in her packet, but stated she did not sign it and was not given the opportunity to review or discuss its contents. The DON confirmed that the signature on the form did not match the resident's known signature and appeared to have been signed by facility staff without proper notation or explanation. Facility policy required that discharge planning begin upon admission and that residents be provided with a Discharge Transition Plan and Notice of Transfer or Discharge, including information about their rights and the reason for discharge. The DON acknowledged that these steps were not followed, and that documentation practices did not meet the facility's standards for accuracy and transparency. The failure to provide the required documentation and notification meant the resident was not properly informed of her discharge or her rights.