Failure to Provide Required Written Transfer and Discharge Notices
Penalty
Summary
The facility failed to provide and document adequate preparation and orientation for resident representatives to ensure safe and orderly transfers or discharges for five residents reviewed. In each case, the facility did not notify the residents or their responsible parties in writing of the transfers or discharges, nor did they provide the reasons for the moves in a language and manner understood by the recipients. Instead, notifications were made verbally, typically via telephone, and there was no evidence of written documentation or provision of required paperwork to the residents, their families, or representatives. This lack of written notification included the absence of information regarding appeal rights, bed-hold policies, and contact information for the State Long-Term Care Ombudsman or protection and advocacy agencies as required by federal regulations. Record reviews revealed that for each resident involved, there was either no documentation of a discharge care plan, no physician orders for transfer or discharge, or no revisions to care plans to reflect planned discharges. For example, one resident with multiple diagnoses including Alzheimer's disease, dementia, and paranoid personality disorder was transferred to a hospital due to acute mental status changes, but the family was not informed until after the transfer and did not receive any written notification or paperwork. Other residents with severe or moderate cognitive impairment were transferred to other facilities without written notice or documented involvement of their representatives in the discharge planning process. In several cases, care plans referenced pre-discharge planning but had not been updated or revised to reflect the actual discharge events. Interviews with staff, including the ADON, DON, and social services personnel, confirmed that the facility's practice was to notify responsible parties verbally and that written notifications were not part of the facility's process or policy. The Ombudsman also reported inconsistencies in receiving discharge logs and noted that the logs lacked detailed information about the reasons for discharge. The facility's own policy and federal regulations require written notice before transfer or discharge, including specific content such as reasons for the move, effective date, location, appeal rights, and contact information for advocacy agencies, none of which were provided or documented for the residents in question.