Failure to Notify Resident Representative of Transfer and Discharge
Penalty
Summary
The facility failed to provide required written notice of transfer or discharge, in a language and manner understandable to the resident and representative, for one resident who was discharged. The resident was an adult male with paranoid schizophrenia, diabetes mellitus, anxiety, hypertension, and a cognitive communication deficit, who had a documented memory problem but was cognitively independent in daily decision-making. His discharge MDS indicated an unplanned discharge to the hospital with no anticipated return. Nursing progress notes documented that he was transferred to the hospital on an emergency basis for abnormal behavior and suicide threats, but the section indicating to whom notice was provided was left unchecked. The facility’s policy required that emergency transfers be treated as facility-initiated transfers, with notice of transfer provided to the resident and resident representative as soon as practicable, and that if a discharge decision was made while the resident was hospitalized, a discharge notice must be sent to the resident, representative, and the State LTC Ombudsman. The resident’s responsible party reported she was not notified of his discharge or transfer to another nursing facility and only learned of his new placement three days after his admission there, during which time he was without clothing, personal belongings, or family involvement. She stated that when she spoke with the DON the day before the transfer, there was no mention of a planned transfer to another facility. The Social Worker acknowledged knowing the resident had been sent to the ER and that another nursing facility accepted him while he was out, and stated she did not speak with the responsible party during the discharge process, though she did notify the ombudsman. The DON stated she called the responsible party about the behavior incident that led to the hospital transfer but did not discuss discharge to the hospital or the other facility and acknowledged that someone should have called the responsible party and that the failure was a violation of resident rights. The Administrator, who was not employed at the time of discharge, also stated the responsible party should have been notified prior to discharge and that the failure violated the rights of the resident and responsible party.
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