Improper Transfer/Discharge Without Written Notice or Appeal Rights
Penalty
Summary
The facility failed to properly manage the transfer and discharge process for a resident diagnosed with Alzheimer's disease, unspecified dementia, unsteadiness on feet, a history of falls, type 2 diabetes mellitus, hearing loss, psychotic disturbance, mood disturbance, and anxiety. The resident's cognitive status was severely impaired, and the responsible party (RP), identified as the resident's granddaughter, was not provided with the required written notice at least 30 days prior to the transfer. The RP was only verbally informed by the Social Services Director (SSD) of the impending transfer due to an alleged abuse incident, and was not given any written documentation or information about the resident's rights to appeal the transfer or discharge. Record review and interviews revealed that the transfer/discharge notice was completed by a Certified Nursing Assistant/Activity Assistant (CNA/AA) who was previously acting as Social Services (SS), rather than by the SSD or through an interdisciplinary team (IDT) discussion. The CNA/AA admitted to initiating the transfer based on her own opinion that the resident was a danger to others, without documentation or input from a medical doctor or the IDT. The administrator confirmed that the CNA/AA should not have been responsible for the transfer/discharge process and that the SSD should have coordinated the process in accordance with facility policy. Facility policy requires a 30-day written notice to the resident and/or their representative, including the reason for transfer/discharge, effective date, location, and information about the right to appeal. In this case, the required written notice and information about the appeal process were not provided to the RP. The SSD also confirmed that she did not provide written notification or advice regarding the right to appeal. As a result, the transfer/discharge was conducted improperly and in violation of the resident's rights.