Failure to Ensure Proper Transfer/Discharge Procedures and Documentation
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the transfer and discharge of a resident to another LTC facility met federal requirements. The resident, who was admitted to the rehabilitation area with a care plan goal to return home but with the understanding that a higher level of care might be needed, was discharged to another LTC facility approximately 75 miles away. The discharge was initiated after the care team determined the resident had not made sufficient progress in therapy and would require long-term care, which the facility stated could not be provided in the rehab unit. However, there was no documentation that the transfer was necessary for the resident's welfare, that the facility could no longer meet the resident's needs, that the resident's health had improved sufficiently, that the health or safety of others was endangered, or that the resident had failed to pay for their stay. Interviews with the resident's daughter revealed that the family was informed of the discharge only a few days prior and felt they were not given adequate time or notice to make alternative arrangements. The daughter also reported not being provided with information on how to appeal the discharge decision. The social worker confirmed that no written discharge notice or appeal information was given to the resident, their representative, or the ombudsman. The facility staff believed that the signed admission agreement addendum, which indicated the resident's consent to cooperate with discharge planning, was sufficient to proceed with the discharge without further documentation or notice. Review of facility policies and federal regulations showed that the facility's own policies required specific conditions to be met and documented for a transfer or discharge, including providing advance notice and information on appeal rights. Despite this, the facility did not provide evidence that any of the regulatory criteria for discharge were met in this case, nor did they follow the required notification and appeal procedures. The deficiency was identified through observation, interviews, record review, and policy review during the survey.