Failure to Provide Written Discharge Notice and Safe Discharge Planning
Penalty
Summary
The facility failed to implement an appropriate discharge plan for a resident by not providing a written discharge notice to the resident and their family, and by not re-evaluating the resident's condition prior to discharge. The resident, who was admitted with chronic hypoxic respiratory failure, recent subdural hemorrhage status post craniotomy, and protein malnutrition, was highly dependent on staff for all activities of daily living, requiring assistance from one or two helpers for basic care tasks. Despite these significant care needs, the facility only communicated discharge plans verbally and did not issue the required 30-day written notice to the resident or their responsible party. Interviews with the responsible party, clinical manager, and case manager confirmed that the discharge process was handled without proper written notification, and the facility's policy did not specify the 30-day written notice requirement. The responsible party and ombudsman both raised concerns about the lack of written notice and the safety of the discharge plan, especially given the resident's ongoing high level of care needs and the family's preference for transfer to another skilled nursing facility. The facility's failure to follow regulatory requirements for discharge notification and planning was confirmed through record review and staff interviews.