F0582

D

Failure to Provide Timely NOMNC and Consistent Discharge Notice for a Cognitively Impaired, Non‑English‑Speaking Resident

Glendale, Arizona Survey Completed on 02-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide a timely Notice of Medicare Non-Coverage (NOMNC) to a resident and/or the resident’s representative in accordance with federal requirements and the facility’s own NOMNC policy. The resident was admitted with significant neurologic and functional impairments, including hemiplegia and hemiparesis following a cerebral infarction, dysphagia, metabolic encephalopathy, type 2 diabetes, and gait abnormalities. Early assessments documented that the resident’s preferred language was not English, that staff were unable to determine if an interpreter was needed, and that the resident had slurred, sometimes understandable speech and severe cognitive impairment as evidenced by very low BIMS scores. A baseline care plan identified an alteration in communication, a language barrier, and aphasic, disorganized, and slurred speech, but did not include checked interventions such as a communication board, written communication, or translation applications.

Throughout the stay, multiple therapy and nursing notes documented the resident’s limited cooperation, refusals of care and therapy, falls, and behavioral symptoms, often in the context of a language barrier and confusion. Nursing and therapy documentation repeatedly showed that staff attempted to communicate verbally or with a language board but were unable to verify understanding due to the language barrier, and there was no evidence of attempts to use an interpreter or translator application. The resident experienced several unwitnessed falls, episodes of combative behavior, refusal of medications, blood glucose checks, and care, and was at times described as barricading herself in her room. A psychiatric consult was ordered but there was no evidence in the clinical record that a psychiatric evaluation was ever completed before discharge. The care plan for behavioral symptoms did not include specific interventions addressing the resident’s primary non‑English language or use of interpreter services.

As the stay progressed, therapy records showed that the resident participated in some OT, PT, and ST sessions but also refused multiple sessions, with therapy staff documenting refusals and minimal progress. Despite speech therapy documentation on one day recommending continuation of the plan of care, PT and ST discharge summaries were later completed indicating dates of service over a short period and noting minimal progress or refusal. Nursing and administrative notes indicated that staff communicated with the resident’s son about concerns for the resident’s safety at night and the need for a caregiver or private sitter, and the son ultimately arranged and paid for a private sitter overnight and then took the resident home. The discharge planning note stated that the NOMNC was signed by the son on a specific date and that discharge home was discussed, but the NOMNC form itself showed Medicare coverage ending on that same date and was actually signed by the son the following day, the day of discharge. There was no documentation that the NOMNC timeframe was waived, that appeal information was provided at the time of the initial notification, or that the discharge was resident‑ or family‑driven or due to the facility’s inability to meet needs as documented by a physician. Interviews with staff and the resident’s son confirmed that the son was informed of discharge plans only shortly before discharge, that he did not receive 48‑hour advance notice or appeal information, and that the facility’s own policy required the NOMNC to be delivered at least two days before Medicare‑covered services ended, which did not occur for this resident.

Additionally, discharge documentation contained conflicting information about the reason and timing of discharge. The Discharge Instructions and Summary listed the reason for discharge as completion of skilled services and stated that the resident participated in therapy as tolerated, while the Notice of Transfer or Discharge cited that the resident’s needs could not be met in the facility and included appeal and Ombudsman information. The notice of transfer or discharge also contained inconsistent dates for when the notice was given. The clinical record lacked a physician note stating that the resident was unsafe to remain in the facility or that her needs could not be met there. Interviews with the LPN discharge nurse, DON, administrator, and other staff showed inconsistent explanations regarding whether the resident met therapy goals, whether she refused therapy, whether the discharge was rushed due to safety concerns, and whether 48‑hour advance notice of Medicare coverage termination and discharge was provided. The facility’s NOMNC policy required delivery of the NOMNC at least two days before Medicare‑covered services end, with proper documentation of communication and appeal rights, but the record for this resident did not show that these requirements were met.