Failure to Follow Proper Involuntary Discharge Procedures
Penalty
Summary
The facility failed to follow proper procedures for the transfer and discharge of a resident with cognitive impairment and significant care needs. The resident, who had a diagnosis of malignant neoplasm of the colon and chronic pain, was admitted for long-term care and had a care plan goal to remain in the facility. After an altercation with another resident, the facility sent the resident to the hospital for a psychological evaluation and subsequently transferred her to another facility without her consent. The resident expressed distress about the transfer, and her family was not informed of their rights or provided with appropriate discharge information. Staff interviews revealed that the resident did not want to leave, and the transfer occurred without the knowledge or preparation of her assigned nurse. The facility did not provide the required involuntary discharge (IVD) paperwork to the resident or her representative, nor did they notify them in writing of the reasons for the move as required by policy. The administrator confirmed that no IVD paperwork was filed, and the social services director was unaware of the transfer until after it had occurred. The ombudsman intervened, and an administrative law judge ordered the facility to take the resident back. Documentation and interviews consistently indicated that the facility did not follow established procedures for involuntary discharge, including providing advance notice and ensuring the resident's preferences and needs were considered.