Failure to Provide Required Transfer/Discharge Notification and Documentation
Penalty
Summary
The facility failed to provide the required written notice and documentation prior to the transfer of a resident with dementia and severe cognitive impairment to another facility. The resident, who exhibited wandering and exit-seeking behaviors, was transferred to a memory care unit without written notification to the resident or her representative, and without notifying the local ombudsman. The clinical records did not contain evidence of a transfer or discharge notice, the reasons for the move, or a signed consent from the resident's representative. Additionally, there was no documentation of a discharge summary or a recapitulation of the resident's stay. Interviews and record reviews revealed that the resident's family member was not informed of the transfer in advance and only learned of the planned admission while visiting the receiving facility. The social worker confirmed that neither a 5-day nor a 30-day discharge notice was provided, and the ombudsman reported not being notified of the transfer. The facility's own discharge policy requires involvement of the resident and family in the discharge planning process and proper notification, which was not followed in this case.