F0628

D

Failure to Notify Ombudsman of 30-Day Discharge Notice

Dimmitt, Texas Survey Completed on 03-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to notify and provide a copy of a 30‑day discharge notice to the Office of the State Long Term Care Ombudsman for a resident who was being discharged. The resident was a 59‑year‑old female admitted with paranoid schizophrenia, unspecified schizophrenia, delusional disorders, unspecified psychosis not due to a substance, post‑traumatic stress disorder, mild cognitive impairment, and diabetes. Her care plan documented risks for falls, behavioral issues, verbal and physical aggression, impaired cognition, and making false statements. A quarterly MDS showed a BIMS score of 15/15, indicating intact cognition. Incident reports documented that she had been the aggressor in hitting staff, throwing objects, refusing care, and making false statements, and she was described as delusional during her stay.

An additional care conference was held where the resident was presented with a 30‑day discharge notice because the facility determined it could not meet her needs. Subsequently, the resident attacked a nurse, the police were called, a judge signed a warrant, and she was transported to a psychiatric facility. During interviews, the Ombudsman stated that no notice of the 30‑day discharge had been received. The administrator reported that the resident had been given the 30‑day notice at the care conference and that the signed notice was given to the former business office manager (BOM) to send to the Ombudsman. The administrator later learned the notice had not been sent and was unable to locate the original signed notice in the facility. A policy related to this process was requested by surveyors but was never provided. The facility therefore failed to ensure required notification of the 30‑day discharge was provided to the Ombudsman.