Failure to Ensure Proper Notification and Involvement in Resident Transfers
Penalty
Summary
The facility failed to ensure safe and compliant transfer and discharge processes for two residents with cognitive impairments. In the first case, a resident with a history of dementia, behavioral disturbances, and episodes of aggression was transferred to a lower level of care (Room and Board) and later to another skilled nursing facility (SNF) without proper documentation of the resident’s or family’s participation in discharge planning. The records showed inconsistent assessments of the resident’s capacity to make decisions, and there was no evidence that the Ombudsman was involved in the discharge process, despite the resident’s inability to sign notifications and the family’s lack of involvement. Additionally, there was no documentation of an interdisciplinary team (IDT) meeting regarding the transfer planning. In the second case, another resident with schizoaffective disorder, cognitive communication deficits, and a public guardian as conservator was transferred to a dementia unit at another facility. The conservator was only notified via voicemail, and there was no documentation of a response or participation in the discharge planning. The Ombudsman was not involved prior to the transfer, and the notification was sent only after the resident had been discharged. The facility staff acknowledged that the conservator was responsible for medical decisions but proceeded with the transfer based on safety concerns without documented consent or involvement from the conservator or Ombudsman. Both cases demonstrated a lack of required documentation and notification related to the residents’ needs, appeal rights, and bed-hold policies. The facility’s own policies require resident or representative participation in discharge planning, proper notification, and documentation of the reasons for transfer or discharge. However, the records reviewed did not show evidence of these requirements being met, particularly regarding the involvement of legal representatives and the Ombudsman for residents lacking capacity to make their own decisions.