The Director of Nursing at Mountain View Convalescent Hospital confirmed that Resident 1 received a Notice of Transfer or Discharge indicating they were going to one assisted living facility, when they actually went to a completely different one.
The resident had originally agreed to be discharged to the first assisted living facility. But Social Services Department staff later notified the Director of Nursing that Resident 1 was instead placed at a second facility. The Director of Nursing said she verified with Social Services that the resident had agreed to this new placement.
However, the facility never provided the resident with a corrected Notice of Transfer or Discharge reflecting the actual destination.
According to facility policy, the discharge notice is provided by a Registered Nurse who reviews medications, follow-up visits, and home health arrangements with the resident before both parties sign the document. The Director of Nursing confirmed this process occurred, but with paperwork showing the wrong facility.
The Director of Nursing reviewed the facility's Transfer or Discharge policy and confirmed it requires residents to be given the specific location where they are going. She acknowledged the signed notice was inaccurate because it failed to reflect the resident's actual destination.
"There is a potential to not have accurate records," the Director of Nursing stated about the incorrect documentation.
The paperwork error created more than just a record-keeping problem. The Director of Nursing explained that home health services might not be aware of the resident's actual location, "potentially resulting in Resident 1 missing on services."
Facility policy titled "Transfer or Discharge, Facility-Initiated" and last reviewed in September 2024 specifically requires that residents and their representatives be notified in writing of "the specific location (such as the name of the new provider or description and or address if the location is a residence) to which the resident is being transferred or discharged."
The facility's documentation policy, also reviewed in September 2024, states that all medical record entries "will be objective, complete, and accurate."
Federal inspectors found no documented evidence that changes were made to Resident 1's discharge notice before the resident left the facility. The original paperwork listing the wrong assisted living facility remained the official record of the transfer.
The case illustrates how administrative errors in nursing home discharges can cascade into problems with continuity of care. When discharge paperwork shows one location but the resident goes elsewhere, home health agencies and other service providers may attempt to deliver care to the wrong facility.
The Director of Nursing's admission that the facility "needs to communicate with home health" highlighted the breakdown in coordination that occurred. Without accurate discharge documentation, essential services like medication management, wound care, or physical therapy could be interrupted or delayed.
Mountain View Convalescent Hospital's violation was classified as causing minimal harm or potential for actual harm to few residents. But the facility's own leadership acknowledged the broader implications of inaccurate discharge documentation on patient safety and care coordination.
The resident at the center of the violation successfully transferred to their intended assisted living facility despite receiving paperwork with the wrong destination. However, the facility's failure to correct the official documentation before discharge violated federal requirements designed to ensure accurate medical records and proper care transitions.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mountain View Conv Hosp from 2025-08-12 including all violations, facility responses, and corrective action plans.
