F0627

D

Failure to Document Basis, Notification, and Planning for Resident Transfer/Discharge

San Antonio, Texas Survey Completed on 01-16-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to properly document and justify a facility-initiated transfer/discharge, to adequately notify and involve the resident’s representatives, and to complete required discharge planning and summaries for a resident with severe dementia. The resident was an elderly female with unspecified dementia with agitation, unspecified dementia with behavioral disturbance, and major depressive disorder. Her annual MDS showed a BIMS score of 06, indicating severely impaired cognition, and documented non‑Alzheimer’s dementia and depression treated with antidepressants. Despite her cognitive impairment, she was independent in self‑care and mobility, and the MDS and a recent QRR summary indicated no verbal or physical behaviors directed toward others in the prior week. Her care plan documented dementia, safety/security issues, and placement in a secure memory care unit, and later revisions noted a history of aggression related to roommate situations and prior resident‑to‑resident altercations, but also that she did not currently have a roommate.

Social service documentation showed that the LMSW contacted one family member (identified as a resident representative and POA) about “solutions” for a recent incident with another resident and that this family member stated she would be okay with a facility closer to her if it came to that alternative to give the resident more room to move around. However, the clinical record from admission forward contained no documentation of a valid regulatory basis for discharge. The discharge summary completed by the DON listed the reason for discharge as requiring a locked unit that allows more space to move around and indicated discharge to another staffed facility, but the physician signature and date lines were not completed. There was no evidence in the record of a written notice of transfer/discharge with reasons for the move, no 30‑day notice, and no documentation that the POA(s) were notified in advance of the actual transfer. The LMSW later sent an email to one POA after the transfer had already occurred, providing the name, address, and contact information of the receiving facility and describing it as a larger locked facility with more space and activities.

Email correspondence between the LMSW and both POAs after the transfer reflected disagreement about whether consent for the move had been given. One POA wrote that she had only agreed to consider a move closer to her, denied agreeing to the suggested facility, and stated that incidents were not discussed at the time. The LMSW responded that he interpreted her statement (“if we have to move her then I guess we have to”) as agreement to transfer if needed. The second POA stated in a phone interview that she did not know why the resident was transferred, believed prior incidents had been handled and the resident was stable, and reported that the decision to move seemed abrupt. She stated she was contacted by the new facility’s admissions coordinator about transfer arrangements before she was aware of any approved transfer and that she told both the admissions coordinator and the LMSW she did not approve the move, yet the resident was transferred the next day. The nursing progress note documented that the resident left the facility via wheelchair with clothing and medications given to transport personnel, but the record contained no documentation of sufficient preparation and orientation of the resident for a safe and orderly transfer, no evidence of an effective discharge planning process involving the resident and both resident representatives, and no discharge summary that included a post‑discharge plan of care developed with the participation of the resident representative(s), as required by facility policy and regulation.

In interviews, the LMSW stated he was responsible for the transfer/discharge process, which should include discussing the transfer with the resident or POA, obtaining agreement, providing written notice, and, if there was disagreement, issuing a 30‑day discharge notice with appeal and Ombudsman information. He acknowledged that he notified one POA on a specific date that the resident would benefit from more space and that he believed she initially agreed to locating another facility. He also acknowledged that the transfer occurred very quickly, that his email notification to the POAs and Ombudsman went out after the resident had already been transferred, and that this was not the facility’s usual practice. He stated he was under pressure to get the resident transferred and that the DON’s relationship with the receiving facility expedited the process. The administrator stated the facility followed its discharge/transfer policy, but record review showed no documented basis for discharge, no documented prior notification to the POAs, no documented discharge planning process involving the resident and representatives, and no post‑discharge plan of care, contrary to the written policy that required individualized discharge planning, written notice for facility‑initiated non‑emergent transfers, and a post‑discharge plan of care.

The facility’s own policy on Discharge or Transfer required that the discharge planning process address each resident’s discharge goals and needs, involve the resident and resident representative and the interdisciplinary team, and that for facility‑initiated non‑emergent transfers or discharges, the facility provide written notice to the resident and representative(s) with reasons for the move at least 30 days in advance, and send a copy to the State LTC Ombudsman. The policy also required a post‑discharge plan of care detailing arrangements made to address the resident’s needs after discharge and instructions given to the resident and representative. Review of the resident’s clinical record from admission onward showed no documentation that these policy requirements were met: there was no valid basis for discharge documented, no evidence of timely written notification to the POAs, no documentation of sufficient preparation and orientation for the resident, no evidence of an implemented and effective discharge planning process involving the resident and both resident representatives, and no discharge summary including a post‑discharge plan of care.