Failure to Provide Individualized Discharge Planning During Facility Transfers
Penalty
Summary
The facility failed to develop and implement individualized discharge plans that incorporated the input and preferences of residents, their representatives, and the interdisciplinary team for 13 out of 27 residents reviewed for transfer and discharge. This failure was observed during a period when the facility was transferring residents to other locations due to necessary building repairs, including collapsed plumbing and other environmental issues. Despite the facility's assertion that residents were given choices of transfer locations, there was no evidence of written notices, comprehensive discharge planning, or documented interdisciplinary team meetings to discuss transfer or discharge options with the residents or their representatives. Several residents and their families reported receiving very short notice—sometimes on the same day—regarding the need to transfer, with little to no discussion of available options or involvement in the planning process. For example, one resident with anxiety and depression was transferred to a sister facility with minimal explanation and no documented care plan updates or interdisciplinary meetings. This resident expressed distress and anxiety about the rushed move and uncertainty about therapy services at the new location. Another resident with moderate cognitive impairment and a goal to return home was also moved with little notice, and his family was not offered alternative facility options closer to their home, resulting in emotional upset and reduced ability to visit. Other residents, including those with severe cognitive impairment or dementia, were similarly transferred without documented discharge planning or adequate communication with their responsible parties. Family members and residents consistently reported a lack of written notice, insufficient discussion of transfer options, and inadequate involvement in the decision-making process. The facility's records did not reflect updates to care plans or evidence of interdisciplinary team involvement in planning for these transfers, and some residents experienced emotional distress as a result of the abrupt and poorly communicated relocations.