Failure to Notify Resident Representatives of Transfers
Penalty
Summary
The facility failed to ensure that resident representatives were appropriately notified of decisions to transfer residents for seven out of nine residents reviewed. According to the facility's own policy, notification of the resident and their representative regarding transfers and the reasons for such transfers must be documented in the clinical record. However, clinical record reviews and interviews with resident representatives revealed that in multiple cases, representatives were not informed by the facility about the transfers. Instead, they learned of the transfers either from the residents themselves or from staff at the receiving facilities. Several residents involved had significant cognitive or mental health diagnoses, including schizoaffective disorder, bipolar disorder, dementia, Alzheimer's disease, and schizophrenia. BIMS scores for these residents ranged from cognitively intact to severely impaired, indicating varying levels of ability to understand and communicate about their care. Despite documentation in progress notes and social service notes stating that families were aware of the discharges, interviews with representatives consistently indicated a lack of direct communication from the facility regarding the transfers. The deficiency was identified through a combination of policy review, clinical record examination, and interviews with both staff and resident representatives. The findings showed a pattern where representatives were not given the opportunity to participate in or be informed about the transfer process, with some expressing confusion and concern about not being notified or consulted. This failure to notify was found to be in violation of state regulations regarding resident rights and facility management responsibilities.