Failure to Provide Required Transfer Notice and Appeal Rights Prior to Resident Discharge
Penalty
Summary
The facility failed to provide the required written notice to a resident and their legal guardian prior to transferring the resident to another nursing facility. The resident, who had severe cognitive impairment and multiple medical diagnoses, was involved in an elopement incident when he exited the building while the fire alarm was sounding and was subsequently returned by staff. Following this event, a referral was made to transfer the resident to a sister facility located approximately 170 miles away, which was described as having a more secure environment suitable for mental health needs. Documentation in the medical record did not include the required details regarding the transfer, such as the reason for transfer, effective date, location, appeal rights, or Ombudsman contact information. The discharge recap form indicated that notice was given to the resident or representative, but there was no evidence that the guardian received the required written notice or information about appeal rights prior to the transfer. Interviews with facility staff confirmed that the decision to transfer was initiated by the facility, and that the required documentation and notifications were not provided or properly recorded in the medical record. The resident's guardian reported that he was not given a choice in the transfer, was not provided with a discharge notice, and did not receive information on how to appeal or contact the Ombudsman. He also expressed concern about the distance to the new facility and the quality of care there. Facility policy requires written notice at least 30 days in advance of a planned discharge or transfer, including information about appeal rights, but this was not followed in this case.