Failure to Ensure Safe and Informed Transfer of Resident with Behavioral Needs
Penalty
Summary
The facility failed to ensure a safe and appropriate transfer of a resident who was experiencing behavioral issues, including agitation and attempts to remove his g-tube, ostomy, and catheter. Despite the resident's confusion, inability to speak English, and need for one-to-one supervision to prevent device removal, the facility arranged for a private non-medical transport to take him to the emergency room after EMS declined to transport, determining it was not a medical emergency. The resident was sent without a staff escort or family member, and upon arrival at the ER, he was left unsupervised in the waiting area, with only a face sheet and medication list provided to the hospital. No clinical documentation or detailed report about his condition or the reason for transfer was sent with him. The facility did not notify or coordinate with the resident's representative (RP) prior to the transfer, which prevented the RP from selecting a preferred hospital or being present to supervise and interpret for the resident. The RP was only notified after the resident was already en route, and the hospital staff expressed concern and frustration upon the resident's arrival without proper documentation or supervision. The resident's inability to communicate and his ongoing agitation further complicated his care upon arrival at the ER. Additionally, the facility failed to update the medical provider (MD/NP) after EMS refused to transport the resident, and did not consider or implement alternative interventions such as PRN medications or physical restraints (e.g., abdominal binder) to address the resident's behaviors prior to transfer. The care plan did not address behavioral concerns, and staff interviews revealed a lack of clear communication and decision-making regarding the resident's needs and the appropriate method of transfer. The facility's actions did not meet regulatory requirements for safe transfer, communication of clinical information, or preparation and orientation of the resident in a manner he could understand.