F0628

D

Failure to Provide Proper Written Discharge Notice to Resident’s Representative

Santa Fe, New Mexico Survey Completed on 01-06-2026

Penalty

Fine: $24,486

Summary

The deficiency involves the facility’s failure to provide proper written notice of discharge to a resident’s representative. The resident in question was admitted with multiple diagnoses including dementia with behavioral disturbance, paroxysmal atrial fibrillation, restlessness and agitation, chronic kidney disease, history of pulmonary embolism, and was receiving palliative care. Following a reported incident on 06/22/25 in which the resident was found on top of another resident with his pants down, attempting to pull down the other resident’s pants and touching her private area, the facility documented a Notice of Intent to Discharge. This notice stated that discharge would be effective 30 days from 06/22/25 due to safety concerns related to the resident’s clinical or behavioral status, and it included appeal contact information. However, the discharge planning conference date was left blank, and the method of delivery was noted only as “verbal and hand deliver,” without clear evidence that the representative actually received the written notice at that time.

A second incident was documented on 06/30/25, when a hospice RN reportedly found the same resident in bed with the same female resident, kissing her and attempting to put his hands down her pants, with his pants partially down. Following this, a second Notice of Intent to Discharge was created, again citing safety of individuals in the facility as the reason for discharge. This second notice identified a 30‑day notice period but left the effective date blank and again omitted a specific date for the discharge planning conference. The letter was signed by the Social Services Director and included appeal contact information, with a handwritten note indicating the wife lived two hours away, did not drive, and that the notice was “also hand delivered.”

In interview, the resident’s wife stated that she was never told about a planned discharge in advance and that she was only called late in the afternoon and told to come pick him up, which she could not do. She reported that the facility told her they could no longer keep him and that they would send him home, and she confirmed she did not receive a written discharge notice and was unaware she could contest the discharge. She described concerns about her ability to care for him at home and indicated she would have preferred that he remain in the facility. In a separate interview, the Social Services Director stated that the first notice was given to the wife after the first incident and that, after the second incident, the Administrator directed an immediate discharge. The SSD reported that both written notices were sent with the driver to give to the wife when the resident was dropped off, but this conflicts with the wife’s statement that she did not receive written notice, demonstrating the facility’s failure to ensure written discharge notice was provided to the resident’s representative.