Failure to Notify Resident Representative and Ombudsman of Proposed Transfer
Penalty
Summary
The facility failed to ensure that a resident’s representative and the Ombudsman were notified of a proposed transfer to another SNF. A complaint was submitted to the Office of Health Care Quality alleging that the facility attempted to transfer the resident for LTC without notifying the designated medical decision maker. The Business Office Manager (BOM) stated that the resident was identified for transfer because the facility was bed locked and needed to open beds for rehab, and also described a practice she called “Quid Pro Quo,” in which facilities with low census contacted them to obtain residents. The BOM believed Social Services had notified the representative but could not confirm this. The resident’s representative, identified as the medical decision maker known to the facility, reported learning of the proposed transfer only after another facility, Kensington Rehab, contacted a family member about accepting the resident. The Social Service Director (SSD) reported receiving a list of residents to be referred out due to the bed lock and stated that her usual process was to send referrals and then contact families. She acknowledged that she did not contact this resident’s representative about the proposed transfer, explaining that she was busy and that Kensington had reached out to the representative quickly. Record review showed that the SSD sent a referral to [NAME] Grove on 01/27/26 and another referral to Kensington Rehab on 02/04/26 before any documented communication with the resident’s representative about the transfer. The DON stated that other facilities do not contact them to obtain residents and denied any “Quid Pro Quo,” and also stated that the facility’s expectation is to discuss a proposed transfer with the resident or representative before sending referrals. The Ombudsman reported not being notified of the bed lock or of residents referred out for transfer.
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