Failure to Complete Required Discharge Planning and Ombudsman Notification
Penalty
Summary
The facility failed to complete the discharge planning process for one of three sampled residents by not providing required notifications and not developing a discharge care plan. Facility policy titled “Admission, Transfer and Discharge” (revised 4/2025) requires that residents not be transferred or discharged unless specific criteria are met and that written notice of transfer or discharge, including reasons and appeal rights, be provided to the resident and representative, with a copy sent to the State Long-Term Care Ombudsman at least 30 days in advance except in limited circumstances. The policy also requires that, when a transfer or discharge is necessary because the resident’s needs cannot be met, the physician document the basis for transfer and the specific needs and services involved. Resident 1, who had Parkinson’s disease and contractures of both ankles, was admitted to the facility on an unspecified date and later had a physician order dated 1/30/26 stating it was acceptable for the resident to go to a board and care if acceptable to the family and resident, and that the resident may go with PT evaluation and home health. A Notice of Proposed Transfer/Discharge for this resident, dated 2/2/26, documented that the notice was provided to the resident and the resident representative on that date, that the notice was mailed to the Long-Term Care Ombudsman on that date, and that the reason for discharge was that the resident’s health had improved sufficiently so that facility services were no longer required. The notice also indicated that notice was given as soon as practicable. However, review of Resident 1’s medical record did not show documented evidence that the Ombudsman was notified of the resident’s discharge as required by facility policy, and the DON confirmed during interview that the notice of transfer/discharge should have been provided to the Ombudsman 30 days in advance. Additionally, review of Resident 1’s care plans showed no care plan developed for a discharge plan, and the DON verified that a discharge plan care plan was not developed for this resident. These inactions constituted a failure to ensure the discharge planning process was thoroughly completed for Resident 1.
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