Incomplete Discharge Notices and Lack of Discharge Planning for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to follow its own transfer and discharge policy and federal requirements when issuing 30‑day discharge notices to two residents. The facility’s policy required that discharge notices be understandable to the resident and include the specific reason for discharge, the discharge date, the exact location (with address) to which the resident would be discharged, the name and address of the local Ombudsman, and information for the state agency responsible for protecting the rights of individuals with mental health illnesses. The policy also required that the notice be provided 30 days prior to discharge and that the Ombudsman’s office be notified when a 30‑day discharge notice was issued. Resident 1, who had borderline personality disorder, bipolar disorder, suicidal ideation, COPD, bowel and bladder incontinence, and functional limitations requiring assistance with ADLs, received a Notice of Involuntary Transfer or Discharge dated 2/20/26. The notice stated that the resident would be discharged to a home or apartment of their choice in another city but did not include a specific address. It listed reasons for discharge as improved health, no longer requiring skilled care, and the facility’s inability to meet the resident’s needs, but omitted information on how to contact the state agency responsible for protecting the rights of people with mental health illnesses. The DON confirmed that the IDT‑Notice of Transfer/Discharge for this resident was incomplete, missing the date the notice was provided, the planned discharge date, specific discharge location, the reason for discharge, Ombudsman and mental health rights contact information, and signatures from the resident and ADON. The record also showed that the resident’s discharge care plan and care conference summary documented that the resident did not have a safe or reasonable discharge location and required staff assistance for medical needs. Resident 2, who had bipolar disorder, schizoaffective disorder, COPD, and intact memory, was also issued an IDT‑Notice of Transfer/Discharge dated 2/20/26. The DON confirmed this notice was incomplete in the same ways: it lacked the date it was provided to the resident, the planned discharge date, specific discharge destination information, the reason for discharge, and contact information for the local Ombudsman and the state agency responsible for protecting the rights of people with mental health illnesses. Resident 2 reported being told by the ADON that they were being discharged in 30 days because they were “high functioning” and confirmed there was no discharge plan in place when the notice was given. The Administrator stated that there was no firm discharge plan in place for either resident at the time the 30‑day notices were issued and that the Administrator was not aware the notices had been provided, despite the expectation that a solid discharge plan should exist before issuing such notices.
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