Failure to Notify Guardian Prior to Resident Discharge and Transfer
Penalty
Summary
The facility failed to notify a resident's guardian prior to the resident's discharge and transfer to another facility. The resident in question had a history of anxiety, traumatic brain injury, aphagia, dysphagia, and convulsions, and was documented as having moderately impaired cognition, requiring supervision for eating and total assistance for all other activities of daily living. The resident had an active court-appointed guardian, and the facility's records showed ongoing communication with the guardian regarding therapy services, equipment needs, and the search for alternative placement due to the facility's VA contract expiring. However, although the guardian was involved in discussions about referrals and equipment, documentation revealed that the guardian was not notified of the resident's actual discharge and transfer until after it had occurred. Staff interviews confirmed that the social services staff did not notify the guardian of the resident's acceptance and transfer to a new facility until the day of discharge, despite having received acceptance from the new facility several days prior. The facility's own discharge planning policy required that residents and their representatives be assisted in choosing appropriate care providers and be provided with accessible information about care options. Administrative staff verified that notification of a resident's representative or guardian prior to transfers or discharges was required, but this did not occur in this instance.