F0628

D

Failure to Provide Required Transfer/Discharge Notices to Representative and Ombudsman

Savoy, Texas Survey Completed on 02-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide required written notices of transfer or discharge to a resident, the resident’s representative, and the State LTC Ombudsman, and to send a copy of the notice to the Ombudsman. The resident involved was an elderly male with dementia, diabetes mellitus, hypertension, and depression, who had a BIMS score of 2 indicating severe cognitive impairment and required supervision for ADLs. Record review showed a facility-initiated discharge protocol dated 01/09/2026 for this resident, with the ombudsman notification portion left incomplete. The discharge MDS dated 01/16/2026 documented that the resident was discharged to an inpatient psychiatric facility.

Further record review of an eTransfer form dated 01/16/2026 at 3:00 PM, completed by the ADON, indicated the resident was transferred to an inpatient psychiatric hospital in a non-emergent transfer, and that the facility physician and resident representative were documented as notified at 9:00 AM the same day. However, the local facility ombudsman stated in interview that she was never notified of the resident’s discharge and only learned of it several days later. The resident’s responsible party reported receiving a 30‑day discharge notice on 01/09/2026 but stated that no one from the facility notified her when the resident was actually discharged on 01/16/2026, and that even during a conversation with the Administrator on the day of discharge, she was not informed that the resident had been discharged.

Multiple staff interviews revealed inconsistent involvement and a lack of clarity regarding who was responsible for notifications. The ADON stated the resident received a 30‑day notice but did not know when, was not involved in the discharge to the behavioral health unit, and did not verify that the family had been contacted, though she acknowledged the family should be notified prior to discharge. The Administrator stated he had discussed the facility’s inability to meet the resident’s needs with the family and believed he had provided a 30‑day notice, but he acknowledged that he forgot to notify the family when the resident was sent to the behavioral hospital and that he did not complete the ombudsman notification section of the facility-initiated discharge protocol. The DON and Social Worker each reported limited or no direct involvement in the actual discharge notifications on the day of transfer, with the Social Worker stating she was unaware of the requirement to notify the ombudsman. RN A reported that, to his knowledge, the discharge process had been completed before his shift and that he was not involved in notifying the responsible party or physician. The facility’s own undated policy stated that for facility-initiated transfers and discharges, including emergent transfers and discharges decided while a resident is hospitalized, notices must be provided to the resident and resident representative and copies sent to the State LTC Ombudsman, which did not occur in this case.