Failure to Provide Resident Rights and Proper Discharge Process During Transfer
Penalty
Summary
The facility failed to ensure that a resident was provided with appropriate choices and rights during a transfer/discharge process. The resident, who had a history of emotional lability, alcohol use, cognitive communication deficits, depression, anxiety disorder, and osteonecrosis, was identified as having moderately impaired cognition and required staff assistance for mobility and daily activities. The care plan noted ineffective coping, a history of trauma, and a preference for female caregivers. The resident also exhibited behavioral issues, including negative statements, isolation, and anxiety, and was on 15-minute safety checks due to recent incidents involving other residents. Despite these complex needs, the facility did not provide the resident with adequate notice or options regarding the transfer. The discharge notice was completed on the same day as the transfer, and the resident was moved to a sister facility within a short timeframe, reportedly without being given the opportunity to discuss the decision with an advocate or to appeal the transfer. The Ombudsman was not notified until several days after the transfer, and the resident did not sign a discharge agreement. Interviews revealed that the resident felt rushed, was not allowed to process the discharge, and experienced emotional distress following the move. The facility's own policies require that residents be given notice, the right to appeal, and the opportunity to remain during the appeal process, none of which were followed in this case. Staff interviews indicated confusion about who initiated the discharge and whether the interdisciplinary team had discussed the transfer. The resident expressed a desire to return to the original facility and reported feeling isolated and depressed at the new location. The transfer was described as sudden, with the resident's belongings hastily packed and some personal items discarded. The facility did not document that the resident's mental health and substance use history were considered in the decision-making process, nor did they ensure the resident was prepared for a safe and supported transition.