Failure to Document and Justify Resident Transfer/Discharge
Penalty
Summary
A deficiency occurred when the facility failed to provide evidence that a transfer from the facility was necessary for a resident's welfare and that the resident's needs could not be met in the facility. The resident involved had diagnoses including schizophrenia, hypertension, benign neoplasm of cranial nerves, and hearing loss, with a legal guardian who was his brother. The resident had severe cognitive impairment and was independent with mobility, with no prior history of elopement until a single incident occurred when the resident exited the facility during a fire alarm. The facility's root cause analysis identified a lack of staff education regarding supervision during fire alarms, as all exit doors became unlocked during such events. Following the elopement incident, the facility initiated a referral to another nursing facility located approximately 170 miles away. Documentation in the medical record was lacking regarding the basis for the transfer, why the resident's needs could not be met at the current facility, or any attempts to address those needs. There was also no documentation explaining how the receiving facility could better meet the resident's needs or was different from the current facility, which also had locked doors. The discharge paperwork did not specify the details of the transfer, and there was no evidence of physician documentation supporting the necessity of the transfer or outlining the specific services the new facility would provide. The resident's guardian was not involved in the selection of the receiving facility and expressed that he did not want the resident to move, citing the distance as a barrier to visitation. The guardian reported feeling that the decision had already been made by the facility and that he was not given a choice. Facility staff interviews confirmed that there was no documentation related to the decision-making process for the transfer, the resident's unmet needs, or efforts to find a facility closer to the guardian. The facility's policy required proper documentation and involvement of the resident or representative, which was not followed in this case.