Failure to Issue Revised Transfer/Discharge Notice After Change in Discharge Destination
Penalty
Summary
The facility failed to provide a new written notice of proposed transfer or discharge when a resident’s discharge destination changed from home to a board and care facility. The resident, admitted with hypertensive heart disease with heart failure and morbid obesity, had an initial physician order dated February 4, 2026, indicating Medicare benefit exhaustion on February 6 and discharge on February 7 to the resident’s home address. A corresponding Notice of Proposed Transfer/Discharge dated February 4 documented an effective discharge date of February 7 and listed the home address as the transfer/discharge destination. Subsequently, a physician order dated February 13 changed the discharge plan to a board and care facility, and the Discharge/Transfer Summary dated February 13 documented that the resident was discharged to a board and care. Despite this change in discharge destination, there was no documented evidence that a new written notice of proposed transfer/discharge reflecting the board and care destination was provided to the resident, the resident representative, or the Ombudsman. During interviews, the Case Manager stated that she provides a new written notice when there are changes in the discharge plan but acknowledged she did not provide a new copy to the Ombudsman for this resident. The DON stated that the SSD or Case Manager should review the notice with the resident and/or representative, complete the written notice, and fax it to the Ombudsman, and confirmed that a new notice should have been prepared for the revised discharge date and destination but there was no documentation that this occurred. The facility’s policy on Transfer or Discharge Notices required written notification to residents or representatives, a copy to the State Long-Term Care Ombudsman, and issuance of a new notice for significant changes such as a change in discharge destination, which was not followed in this case.
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