Failure to Notify Residents and Representatives of Transfer/Discharge and Appeal Rights
Penalty
Summary
The facility failed to properly notify residents and their representatives of transfers or discharges, as well as their rights to appeal and information regarding bed-hold policies, for two out of three sampled residents. In the case of the first resident, who had severe cognitive impairment and was unable to make decisions, the facility did not ensure that the resident's representative, who held power of attorney and was the legally recognized decision-maker, received the required Notice of Proposed Transfer/Discharge (NTD). Although the NTD was completed and included necessary information about the transfer and appeal rights, it was not signed by the representative, and the representative later confirmed she did not receive the notice. Staff signed the NTD instead of the resident or representative, contrary to facility policy. For the second resident, who was cognitively intact and able to make decisions, the facility also failed to ensure proper notification procedures were followed. The NTD for this resident was signed by a staff member rather than the resident or their representative. Interviews with staff revealed that if the resident or representative was not present at the time of transfer, the NTD was not mailed to the representative as required. The facility's own policy stated that the NTD should be mailed to the representative the next day if not signed in person, but there was no documentation that this occurred. Interviews with facility leadership, including the DON and Administrator, confirmed that the required notifications were not mailed to the residents' representatives and that the facility's policy and procedure for notification and documentation were not followed. The lack of proper notification meant that the residents' representatives were not informed of their right to appeal the transfer or discharge, nor were they provided with contact information for the Ombudsman or the Department, as required by regulation and facility policy.