F0628

D

Failure to Notify Ombudsman of Resident Discharges

Scottsdale, Arizona Survey Completed on 01-07-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide the Ombudsman with a copy of the written notice of discharge for two residents who were discharged from skilled care. For the first resident, admitted with metabolic encephalopathy, COPD, and anxiety for post‑operative rehabilitation, the clinical record showed ongoing discharge planning toward return to home, later updated to discharge to home with hospice services. Multiple documents, including skilled needs reviews, IDT care plan conference notes, therapy notes, a discharge summary, a discharge transfer evaluation, physician orders, and a discharge MDS, confirmed that the resident was discharged home on a specified date. However, there was no evidence in the clinical record that the Ombudsman was notified or provided a copy of the discharge notice for this resident.

For the second resident, admitted with speech language deficits and type II diabetes, the record contained physician orders indicating completion of the skilled inpatient stay and discharge to home, an IDT care plan conference note documenting a plan to discharge home with family, a discharge summary confirming the discharge date and that the resident would be discharged with medications, and a progress note stating the resident was discharged home in stable condition with family and belongings. Despite this documentation of discharge, there was no evidence that the Ombudsman was notified or given a copy of the discharge notice for this resident. In an interview, the DON explained the usual process for notifying residents and/or representatives in writing about discharge, including appeal rights, bed‑hold policy, and Ombudsman contact information, but the facility’s written policy on transfer or discharge notice did not include a requirement to notify the Ombudsman.