Failure to Provide Medically-Related Social Services for Resident Transfer Requests
Penalty
Summary
The facility failed to provide medically-related social services to a resident with cerebral palsy and paresthesia of the skin by not honoring repeated requests to be transferred to a facility closer to his home. The resident, who had been admitted in 2019, consistently expressed his desire to move closer to his hometown, as documented in care plans, social service assessments, and progress notes. Despite these documented requests, the facility did not proactively pursue alternate placement or maintain documentation of referral efforts as required by facility policy. Interviews with the Social Service Director (SSD), nursing staff, and the Health Information Manager (HIM) confirmed that the resident's requests for transfer were known to staff over several years. The SSD acknowledged that although referrals were reportedly sent to other facilities, there was no documentation to support this, and the HIM confirmed that no such records were received or uploaded into the resident's medical file. The facility's policy required social services to document all referrals in the resident's medical record, which was not followed in this case. The resident's ongoing requests and the lack of action led to emotional distress, as evidenced by multiple progress notes and interviews indicating the resident's frustration and a reported episode of self-harm. Nursing staff and the Director of Nursing (DON) confirmed that the resident's psychosocial well-being was negatively affected by the facility's failure to act on his transfer requests. The DON also confirmed that the facility's policy and expectations regarding documentation and proactive placement efforts were not met.