Failure to Prevent Mental Anguish and Neglect During Facility Closure and Resident Transfers
Penalty
Summary
The facility failed to protect multiple residents from mental anguish and neglect during a facility closure and transfer process. Several residents reported being given insufficient notice about the closure, with some stating they were told they had to leave immediately and were not provided with choices regarding their new placement. Residents described the process as rushed and traumatic, with some not receiving assistance in packing their belongings, and others being separated from friends or loved ones. One resident reported being transferred to a facility far from their family, and another was placed in a facility without appropriate security measures for their cognitive condition, causing distress to their power of attorney. Medication management during the transfer was inadequate. Multiple residents did not receive all of their prescribed medications upon discharge or arrival at the new facility. One resident with HIV missed several days of critical medication due to the facility not sending it with them, and the receiving facility was unable to obtain a timely refill. Another resident did not receive a glucometer or a complete supply of insulin, and was missing other essential medications. The receiving facilities had to use emergency supplies or work to refill missing medications, and communication with the original facility was reported as poor or unresponsive. Environmental conditions prior to transfer were also cited as contributing to residents' distress, with reports of lack of hot water, unsanitary conditions, and infestations. Residents expressed feelings of helplessness, anxiety, sadness, and trauma as a result of the abrupt closure, lack of communication, and insufficient support during the transition. The facility's actions and inactions resulted in psychosocial harm and failed to meet the standard of care required to prevent neglect and mental anguish.