Failure to Provide Required Transfer/Discharge Notice and Ombudsman Notification
Penalty
Summary
The deficiency involves the facility’s failure to provide a required written notice of transfer/discharge to a resident and to the State Long-Term Care Ombudsman when the resident was transferred to the emergency room and subsequently discharged to a sister facility. The resident had been admitted in 2025 with diagnoses including traumatic subarachnoid hemorrhage and unspecified intracranial injury, and a physician progress note documented dementia, cognitive decline secondary to traumatic brain injury, anxiety, and a need for frequent reorientation and redirection. The admission record identified the resident as his own responsible party, and the Social Services Director reported that the resident had a BIMS score of 13, indicating cognitive intactness, prior to transfer to the sister facility. On the date of the incident, the resident was involved in a resident-to-resident altercation in which another resident struck him multiple times on the left side of the face. Facility documentation described physical abuse with swelling of the left wrist and lower left eye, and progress notes indicated the resident was struck multiple times and transported by ambulance to the hospital. Interviews with the ADON, DON, and Administrator confirmed that the resident was sent to the hospital following the altercation and that the decision was later made by facility leadership to discharge the resident and have him admitted to a sister facility, characterized as being for the resident’s safety and to keep him separated from the other resident involved in the altercations. The Administrator stated she contacted the hospital and informed them that, upon discharge from the emergency room, the resident would be admitted to the sister facility, and the hospital emergency record documented this communication. However, the Administrator, Social Services Director, and other staff were unable to locate any documentation that the resident was notified of the facility-initiated discharge or transfer to the sister facility, and the Administrator confirmed that a discharge notice was not given. The Ombudsman confirmed that no notice of transfer/discharge was received regarding this resident. This was inconsistent with the facility’s own transfer and discharge policy, which requires written notice to the resident and resident representative, including reasons for transfer/discharge, effective date, receiving location, appeal rights, and Ombudsman contact information, and requires evidence that notice was sent to the Ombudsman.
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