Failure to Assist Resident with Discharge Planning and Transfer Requests
Penalty
Summary
The facility failed to adequately assist a resident in discharge planning, specifically in facilitating a transfer to another facility closer to the resident's family. The resident, who is cognitively intact, expressed a clear desire to move and provided a list of preferred facilities. Despite repeated requests and involvement from the Ombudsman, there was minimal documented action by the facility's Social Services staff. Only one referral was documented as sent, with no evidence of follow-up or confirmation of receipt, and no further documented efforts or communication with the suggested facilities. The resident's chart lacked documentation of referrals or follow-up actions from December 2024 to the present. Interviews with facility staff and the Ombudsman confirmed that the resident's requests were not actively pursued, and the administrator of a local facility reported never receiving a referral. Email correspondence showed ongoing requests from the Ombudsman for updates and additional facility options, but these were not responded to by the facility. The facility's own discharge planning policy emphasizes preparation and coordination, but these steps were not followed in this case, resulting in a lack of progress toward meeting the resident's expressed needs and preferences for transfer.