Failure to Provide Timely Written Transfer Notices and Ombudsman Notification
Penalty
Summary
The facility failed to provide timely written notification to residents and/or their representatives regarding the reason for transfer out of the facility, and also failed to notify the Ombudsman of resident transfers. This deficiency was identified for nine residents who were transferred as part of a temporary closure due to facility repairs, including plumbing and kitchen renovations. Interviews and record reviews revealed that residents and their families were often informed of the need to transfer only verbally and with very short notice, sometimes on the same day as the transfer, and did not receive the required 30-day written notice or information about appeal rights or bed-hold policies. Several residents, including those with cognitive impairments and those who were their own responsible parties, reported not receiving any written explanation for their transfer or being given adequate time to prepare. In some cases, family members or POAs were contacted by phone shortly before the transfer, and choices of alternative facilities were limited to those owned by the same corporation. Documentation in the medical records did not include evidence of written notices, discharge planning meetings, or discussions of all available options, and residents were not provided with information about their rights or the reasons for transfer in writing. The Ombudsman was not formally notified by the facility about the transfers or the temporary closure, learning of the situation only through a third party. The facility administrator and other staff acknowledged that written notices were not provided, and that the process was not treated as an emergency evacuation. Residents and their representatives expressed frustration and inconvenience due to the lack of notice and limited options, and some reported that the move made it more difficult for family members to visit. The deficiency was observed through interviews, record reviews, and direct observations of residents in their new locations.