Failure to Ensure Proper Communication and Acceptance Prior to Resident Transfer
Penalty
Summary
The facility failed to ensure appropriate communication and acceptance from the receiving health care institution prior to the transfer of a resident with severe cognitive impairment and aggressive behaviors. The resident, who had diagnoses including muscle wasting, gait abnormalities, muscle weakness, and dementia, was being considered for transfer due to aggressive actions such as kicking, biting, and threatening staff. The social worker submitted a referral to a behavioral hospital, but at the end of her shift, the resident had not yet been accepted. Despite this, the DON facilitated the resident's transfer to a medical center without confirmation of acceptance or proper communication regarding the resident's needs. Upon arrival at the medical center, staff there were unaware of the reason for the transfer and had not been informed of the resident's behavioral issues or need for psychiatric services. The resident was subsequently returned to the facility within a few hours. Interviews with facility staff, including the ADON and Clinical Services Director, confirmed that the transfer was not conducted according to policy, which requires prior acceptance and notification of the receiving facility. The administrator stated she was unaware the transfer occurred without acceptance and emphasized that the expectation is for acceptance to be obtained before any transfer.