Failure to Provide Medically-Related Social Services and Notify Ombudsman During Transfers and Discharges
Penalty
Summary
The facility failed to provide appropriate medically-related social services to meet residents' needs during transfers to the hospital and discharges to the community. Specifically, for one resident with complex medical conditions, including Parkinson's disease, seizures, anxiety, depression, and a recent leg amputation, the facility did not ensure that the basis for discharge was supported by documentation in the medical record. The resident was assessed as cognitively intact but dependent on staff for several activities of daily living (ADLs) and had previously expressed a desire to remain in the facility until fitted with a prosthesis and able to secure appropriate caregiver support in the community. Despite this, the facility issued a 30-day discharge notice citing endangerment to the safety of others, but there was no documentation in the medical record or incident logs to support that the resident had engaged in behaviors that endangered themselves or others. Staff interviews and progress notes did not corroborate the stated reason for discharge, and the discharge summary later listed 'Condition Improved' as the reason for discharge, which contradicted the original notice. Additionally, the facility failed to notify the Office of the State LTC Ombudsman of 37 hospital transfers over a five-month period. The facility's policy required notification of the Ombudsman for planned discharges, but staff were unaware that hospital transfers also required notification. As a result, the Ombudsman was not informed of any of the hospital transfers, which prevented the Ombudsman from advocating for residents' rights during these transitions. Staff interviews confirmed that the practice of notifying the Ombudsman for hospital transfers was not in place, and the responsible staff member had not received training on this requirement. The facility's discharge planning policy required the interdisciplinary team to document the evaluation of residents' discharge needs, the discharge plan, and discussions with the resident or their advocate. However, in the case reviewed, there was no evidence that the discharge was based on a thorough assessment or that the resident's needs and preferences were adequately considered or documented. The lack of documentation and communication with the resident's representative further contributed to the deficiency, as the representative was not kept informed of the discharge process or the reasons behind it.