F0627

D

Failure to Provide Required Discharge Notice and Documentation for a Resident Transferred to Another SNF

Kansas City, Missouri Survey Completed on 01-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide a required discharge notice, follow appropriate discharge procedures, and complete discharge documentation for a resident who was moved to another skilled nursing facility. The facility had a written Transfer and Discharge policy requiring that residents be transferred or discharged only under specific conditions, based on a physician order (unless leaving against medical advice), and that reasonable advance notice—typically 30 days—be given to the resident and their representative, with certain exceptions. The policy also required that a written notice of proposed transfer/discharge be provided to the resident and their representative, containing the reason for discharge, effective date, destination information, appeal rights, and Ombudsman contact information, and that a copy be sent to the State Long Term Care Ombudsman for facility-initiated discharges. Documentation related to discharge, including a discharge summary and post-discharge plan, was to be maintained in the medical record.

The resident at issue was admitted from a hospital and later discharged to another skilled nursing facility within the same company. The resident had multiple diagnoses, including fluid overload, atrial fibrillation, cognitive communication deficit, repeated falls, lack of coordination, dementia with behavioral disturbance, heart disease, and urinary incontinence. An admission MDS showed adequate hearing, clear speech, ability to make self-understood and understand others, and a BIMS score of 10 indicating moderately impaired cognition, with no behaviors noted during that assessment. The comprehensive care plan included interventions for smoking-related lung function, ADLs, behaviors related to inappropriate sexual comments, communication, cardiac status, edema/fluid overload, cognition related to dementia, fall risk, mood problems related to new long-term care admission, nutrition, skin integrity, and bladder incontinence. The resident had a Durable Power of Attorney (DPOA) document naming a family member (Family Member A) as the Power of Attorney for financial, contractual, medical, legal, and personal matters.

Despite these requirements and the identified DPOA, the facility did not obtain or document a physician order to discharge the resident to another skilled nursing facility, and the electronic medical record lacked a discharge notice, discharge summary, discharge care plan, or physician orders related to the discharge and admission to the receiving facility. Progress notes showed that on one date the Social Services Designee spoke with a family member who was not the DPOA to update them on the resident’s discharge progress, and later the Admissions Director documented that the resident would discharge to another skilled facility within the company on a specified day and time, with transport arranged, personal effects sent with the resident and family, and current documentation and discharge order to be sent. However, the DPOA (Family Member A) reported not being notified of the discharge, not receiving any discharge paperwork or discharge notice, and not being contacted by or signing admission paperwork for the receiving facility, and stated they would not have chosen that facility. The DON stated an expectation that staff notify the DPOA/representative, obtain approval or give a 30‑day notice, and ensure the accepting facility could meet the resident’s needs. The Administrator acknowledged that a discharge notice was not completed because staff believed the move to another skilled nursing facility was a transfer rather than a discharge, even though social services was responsible for discharge planning documentation and providing discharge notices as required by regulation.

There was no indication in the record that, once the failure to provide a discharge notice was identified, the facility subsequently administered a discharge notice to the resident or the resident’s representative. The lack of required notice, absence of a physician discharge order, and missing discharge documentation in the medical record, combined with communication directed to a non‑DPOA family member instead of the designated DPOA, formed the basis of the deficiency identified by surveyors.