Failure to Ensure Safe and Orderly Resident Discharge
Penalty
Summary
The facility failed to ensure a safe and orderly transfer or discharge for three residents by not following required procedures and documentation. For one resident with depression, anxiety disorder, and schizophrenia, the facility discharged the individual to another skilled nursing facility without a physician's order specifying the discharge location, without indicating the appropriate reason for discharge, and without providing or obtaining a signed Notice of Transfer/Discharge (NTD) from the resident. Interviews with staff confirmed that the NTD was not provided or signed prior to discharge, and the resident's discharge goal was to move to a lower-level care facility, not another skilled nursing facility. Another resident with chronic obstructive pulmonary disease, diabetes mellitus, and schizophrenia was discharged to a different skilled nursing facility without a documented reason for discharge and without a signed NTD. Staff interviews and record reviews confirmed that the required notice and consent were not obtained prior to the discharge, and the discharge reason was not clarified or documented on the NTD form. A third resident, who had hypertension, chronic kidney disease, dementia, and schizophrenia, and was severely impaired in cognitive skills, was discharged to an independent living home with home health services, despite requiring assistance with activities of daily living such as dressing and personal hygiene. Staff acknowledged that the discharge location was inappropriate given the resident's needs, and documentation confirmed the resident was not independent in ADLs at the time of discharge. Facility policies required notification, documentation, and preparation for discharge, but these were not followed in these cases.