Failure to Provide Required Written Transfer Notices and Appeal Rights
Penalty
Summary
The facility failed to provide written notification to a resident and her representative regarding transfers to a psychiatric hospital, including the reasons for transfer, effective date, location, statement of appeal rights, and information about the bed-hold policy. The resident, who had diagnoses of dementia, diabetes type II, major depressive disorder, and multiple fractures, exhibited wandering and behavioral symptoms that interfered with her care and the privacy of others. She was transferred to a psychiatric hospital on two occasions due to these behaviors, but neither she nor her representative received the required written notice. Record reviews showed that while the facility's social worker and staff communicated verbally with the resident's representative about the transfers and the resident's behaviors, there was no documentation of written notices being provided. The facility's own policy required that such notices include specific information about the transfer or discharge, appeal rights, and contact information for the state ombudsman, but this was not followed. Interviews with the administrator confirmed that written notices were not provided for hospital transfers, and there was an assumption that residents would be allowed to return. The resident's care plan included interventions for impaired coping, knowledge deficit, and elopement risk, but these did not address the lack of written notification for transfers. The administrator acknowledged that the facility could not meet the resident's needs due to her behaviors and that the transfer was considered involuntary, yet the required written documentation was not completed or given to the resident or her representative.