Failure to Notify Resident and Ombudsman Prior to Transfer/Discharge
Penalty
Summary
The facility failed to provide timely and appropriate notification to a resident, the resident's representative, and the State Long-Term Care (LTC) Ombudsman prior to a transfer/discharge. The transfer was initiated by corporate staff due to the resident's status as a sex offender, which was not permitted at the facility's location. The Administrator and Social Service Director (SSD) did not issue a written notice of transfer/discharge to the resident or notify the Ombudsman, as required by facility policy and federal regulations. The resident involved had a history of high blood pressure, diabetes, stroke, and seizure disorder, and required partial to moderate assistance with activities of daily living. The resident was cognitively intact, with no noted mood or behavioral issues, and was his/her own responsible party. Documentation showed that the SSD spoke only with the resident's family member about the transfer, who had no objections, but did not communicate directly with the resident regarding the discharge or provide written notice. The Administrator confirmed that she did not speak with the resident, did not issue a discharge notice, and did not contact the State LTC Ombudsman. The transfer was executed by arranging for the resident to be transported by taxi to another facility, accompanied by staff, with medications sent for safety and remaining belongings to follow. The facility's failure to follow its own policy and regulatory requirements regarding notification and documentation led to the deficiency.