F0561

D

Failure to Honor Resident’s Request to Transfer Closer to Family

Plattsburg, Missouri Survey Completed on 10-03-2025

Penalty

Fine: $33,135

Summary

The deficiency involves the facility’s failure to honor a cognitively intact resident’s right to self-determination and choice regarding transfer to another LTC facility closer to the resident’s family. The resident, who had intact cognition, was independent in ADLs, and had diagnoses including insulin-dependent diabetes, kidney disease, cervical cancer, and heart disease, had lived in the facility for three years and requested to move to a neighboring facility to be closer to a special-needs child living in a group home. The resident reported having made this request months earlier to social services and administrative staff, stating that no one had followed up and expressing emotional distress, saying that their rights had been violated.

Record review from June through October showed no nursing or social service documentation of the resident’s wish to discharge to another LTC facility, no follow-up on the request, and no communication to the resident about the status of the transfer. The care plan contained no documentation of the resident’s desire to move closer to the child. The Social Services Director stated that an initial admission referral had been sent in May to the requested facility but could not locate documentation of the request, referral, follow-up, or timeline, and acknowledged that the referral had not been followed up, documented, or communicated to the resident. The Administrator was aware of the request and had only a single text message to the neighboring facility asking about referral status, with no further documentation of active work on the referral. The admissions nurse at the neighboring facility reported that updated nursing notes had been requested more than once, that referrals expired after 30 days, and that they were still waiting on an updated referral, with the original referral having been sent four months earlier.