Failure to Provide Required Written Transfer Notice and Ombudsman Notification
Penalty
Summary
The deficiency involves the facility’s failure to provide required written notice of a transfer, including appeal rights and bed-hold/transfer information, to a resident and to notify the State Long-Term Care Ombudsman of the transfer. A cognitively intact female resident with Parkinsonism, depression, and schizoaffective disorder was admitted in mid-February 2025. Her MDS assessment showed a BIMS score of 14, indicating no cognitive impairment, and Section Q reflected no discharge plan in place and no referral to the Local Contact Agency, with the reason documented as a discharge date within three or fewer months. Despite this, the resident was transferred to a sister facility without written documentation of the transfer details being provided to her. Surveyors attempted to contact the resident and her daughter by telephone and email in February 2026 but were unable to reach them or leave a message. During the investigation, the Ombudsman reported concern that the facility did not notify the resident in writing of why she was moved and stated that the resident told her she did not know why she had been transferred. The Ombudsman further stated that facility staff had not notified her office of any discharge or transfer and that she only learned of the transfer when she visited another facility and the resident informed her of the move. The administrator reported that the social worker, who was on leave, had arranged the transfer to a sister facility due to ongoing problems between the resident and her roommate and the resident’s desire for a private room, which she did not qualify for at the original facility. The administrator stated that the resident agreed to the transfer but acknowledged that she could not locate any written correspondence or notification documenting the transfer. She also stated that the facility had not been in the practice of notifying the Ombudsman of transfers and discharges unless there were special circumstances, despite the facility’s written policy requiring written notice to the resident and representative at least 30 days before a non-emergency transfer or discharge, including the reason, effective date, new location, appeal rights, and Ombudsman contact information.
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