Based on interview and record review, conducted during a site visit on 1/16/24, it was determined the facility failed to evaluate the resident's health, medical, behavioral or care needs within a reasonable time, but no later than 24 hours after the resident had been deemed ready for discharge for 1 of 1 sampled resident (# 1). Findings include, but are not limited to:

During an interview on 11/16/23, Staff 3 (Executive Director) stated s/he had been in contact with the hospital via phone and acknowledged Resident 1 was ready for discharge on a Friday. However, s/he informed hospital staff that an assessment could not be completed until the following Monday due to staffing shortages.

Documented communications between the facility and the hospital pertaining to Resident 1's discharge and assessment were requested. The facility was unable to provide Resident 1's assessments done at the hospital, nor email or phone converstions with hospital staff or the resident's family.

Resident 1's Providence Hospital Discharge Summary, printed 04/14/23, indicated:

"DME hospital bed orders have been placed for delivery to home prior to discharge effective 04/13/23;"

"A patient lift is required for transfers between bed and a chair, wheelchair, or commode;" and

"The patient will be discharged to Bonaventure ALF on 04/14/2023."

Resident 1's Charting Notes, dated 04/14/23 to 05/03/23, indicated:

04/14/23: Resident on alert due to new move in; and

04/30/23: RN Assessment/Alert due to new move in.

Resident 1's MAR, dated 04/01/23 through 04/30/23 indicated Resident 1 was out of the facility from 04/16/23 through 04/28/23.

Resident 1 was unavailable for interview as s/he no longer resided at the facility.

It was confirmed the facility failed to evaluate the resident's health, medical, behavioral or care needs within a reasonable time, but no later than 24 hours after the resident has been deemed ready for discharge.

The findings of the investigation were reviewed with and acknowledged by Staff 2 (Assisted Living Director) and Staff 3 on 11/16/23.

Verbal Plan of Correction: Executive Director has had email communication with Policy Analyst on correction and policy review for future situations. The Executive Director will coordinate future movement and/or the return of residents, ensuring that a staff member is available, even on weekends, to complete assessments within the 24-hour timeframe required. The Executive Director will ensure that verbal communications with external care partners are documented in the resident's charting notes.