Failure to Inform and Document Resident Transfer for Psychiatric Evaluation
Penalty
Summary
The facility failed to follow its discharge and change in resident condition policies during the transfer of a cognitively intact male resident with multiple diagnoses, including osteoarthritis, diabetes, morbid obesity, and nicotine dependence. The resident was transferred to the hospital for a psychiatric evaluation without being informed in advance of the reason for the transfer, as required by facility policy. The resident reported being awakened in the early morning hours and told by a nurse that he was going to the hospital, but was not given an explanation. He initially refused the transfer and called 911, resulting in police involvement before he ultimately agreed to go to the hospital. Documentation in the resident's medical record was incomplete. There was no record of the physician's order for the transfer, no documentation of the behaviors that led to the decision, and no evidence that the resident was informed of the transfer or the reason for it. Staff interviews confirmed that while some steps may have been taken, such as obtaining a physician's order and informing the resident, these actions were not documented as required by policy. The facility's discharge and change in condition policies require notification of the resident and responsible party, physician involvement, and thorough documentation in the medical record, none of which were fully met in this case. The incident was triggered by reports of the resident being verbally aggressive toward other residents and staff, leading to a decision to initiate an involuntary petition for psychiatric evaluation. Despite the facility's stated process for handling such behaviors, including assessment by social services, administrative review, and physician orders, the required documentation and communication steps were not followed or recorded. The lack of documentation and failure to inform the resident in advance constituted a violation of both facility policy and resident rights.