F0628

D

Failure to Include Required Appeal and Ombudsman Information on 30‑Day Discharge Notices

Saint Paul, Minnesota Survey Completed on 01-15-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that 30‑day discharge notices contained all required information related to residents’ needs, appeal rights, and ombudsman contact information for two residents. One resident had multiple diagnoses including alcoholic cirrhosis, chronic hepatitis C, COPD, left above‑knee amputation, anxiety disorder, and depression, and was cognitively intact and independent with transfers. This resident had a smoking care plan identifying him as a smoker with interventions to instruct him on facility smoking policies and safety. Progress notes documented that he was observed smoking in his room on one evening, was reminded of the policy and risks, and stated he did not care and would continue due to the cold weather. A subsequent note indicated he continued to smoke in his room despite multiple staff requests to stop. A 30‑day notice was then issued, but the progress note did not specify the reasons for the notice, and the discharge form contained an incorrect transfer date and lacked required contact information for the state agency appeals coordinator and the LTC ombudsman.

The same resident later produced two discharge notices from his drawer, one older notice and a second dated later with a list of homeless shelters stapled to the back. He stated he believed he was being discharged for being mean to other residents, was unaware that the notice was related to smoking policy violations, and reported that ombudsman contact information was not listed on the form. He indicated he had to obtain the ombudsman’s number from a staff member and that the facility only provided him with a list of homeless shelters, which he did not want to use. The ADON reported she had been instructed by the administrator in training to give this resident a 30‑day discharge notice due to repeated smoking policy violations and acknowledged she did not notice that the ombudsman contact section on the form was blank.

A second resident, with diagnoses including diabetes mellitus, chronic pain syndrome, opioid dependence, depression, and anxiety, was also cognitively intact and independent with transfers and ADLs. This resident’s care plan identified him as a vulnerable adult due to alcohol/substance abuse and traumatic life events, with interventions to notify the provider if he posed a potential threat to self or others. His discharge form, signed by the ADON, stated he would be transferred and cited endangerment to the safety and health of individuals in the facility as the reason, but similarly omitted the email address for the state agency appeals coordinator and the contact information for the LTC ombudsman. The ADON stated this resident was given a 30‑day notice because he was found using illicit drugs in the facility and required 911 transport to the hospital. The resident reported that the ombudsman contact information was not on his notice and that he initially believed his only option was to plead with the administrator to stay because the facility had not helped him find another placement. The LTC ombudsman stated that 30‑day notices should include ombudsman contact information to allow assistance with the appeal process and reported a delay in receiving copies of the discharge notices from the facility, despite an earlier request.