Failure to Issue Involuntary Discharge Notice and Provide Required Transfer Documentation
Penalty
Summary
The facility failed to issue an involuntary discharge notice to a resident prior to transferring the resident to the hospital, which resulted in the resident not being informed of their legal rights as required for residents in long-term care. The resident, who had been admitted to the facility and later transferred to the hospital due to behaviors such as wandering, aggression, and combativeness, did not have documentation in their medical record indicating that care plan goals or required transfer information were sent to the hospital. Additionally, there was no evidence that the resident was assessed by facility psychiatric services or a facility physician prior to the transfer. Interviews with facility staff, including the DON and hospital liaison, revealed that the decision to send the resident back to the hospital was made by the DON, and the hospital was informed that the resident would not be returning to the facility. The hospital social workers confirmed that no paperwork, belongings, or bed hold notice accompanied the resident upon transfer, and the facility medical director stated they had no input in the decision. The lack of proper documentation and communication regarding the resident's transfer and discharge process led to the deficiency.