Failure to Uphold Resident Rights in Discharge Planning
Penalty
Summary
The facility failed to uphold resident rights for one resident by not implementing an effective discharge planning process that considered the goals of the resident's Health Care Proxy (HCP). The resident, who had severe cognitive impairment due to dementia and other psychiatric diagnoses, had an activated HCP, with a family member designated to make decisions. The family's stated goal was to have the resident transferred to a skilled nursing facility closer to them, as the current location posed a significant financial and logistical burden for visits. Documentation in the resident's care plan and social services notes indicated that the facility was aware of the family's preference and the hardship caused by the distance. The care plan included interventions for providing information and referrals to assist with the transfer. However, after an initial referral attempt in early 2025, there was no evidence of further referrals or follow-up calls to other facilities for placement. The social worker acknowledged that no additional referrals had been made in the past six months, despite ongoing requests and discussions with the family. Interviews with the family member and facility staff confirmed that the facility did not consistently pursue alternate placement options or maintain documentation of referral efforts. The administrator and social worker both recognized that more should have been done to assist with the transfer, especially given the family's repeated requests. The facility was unable to provide documentation of referrals or follow-up actions to the survey team at the time of the survey exit.