Improper Involuntary Discharge and Failure to Honor Appeal Rights
Penalty
Summary
The deficiency involves the facility’s failure to provide an appropriate and lawful discharge and to honor an appeal of an involuntary transfer for one resident. The facility’s transfer and discharge policy, dated June 2020, required that residents be transferred or discharged only for specific reasons, that a 30‑day written notice be provided with the effective date, receiving facility information, and appeal rights, and that residents not be transferred or discharged while an appeal was pending. For this resident, a 30‑Day Notice of Involuntary Discharge dated 1/15/26 cited failure to pay as the reason and listed allowable outstanding charges of $17,809.40, but the form did not include the current facility name and, when later emailed to the Ombudsman, did not include the address of the receiving facility. The notice also contained an incorrect discharge date (2/7/26 instead of 2/17/26), and the facility proceeded with discharge planning based on this notice. The resident had a history of paraplegia, cognitive communication deficit, and major depressive disorder, and was assessed as cognitively intact on the quarterly MDS dated 1/14/26. The Administrator reported that the resident’s family member, who held DPOA that was not enacted, initially agreed via text on 1/15/26 to the transfer and asked where the resident would be moved, and the Administrator identified the new facility. The Administrator stated that a care plan meeting scheduled for 1/15/26 was canceled by the family with the resident’s agreement, and that at first the resident wanted to leave. The day before the scheduled transfer, the resident reported that the family member told them not to leave, but the next morning the resident reportedly said they were okay with the transfer and asked that the family member meet them at the new facility. The resident’s care plan, updated 2/9/26, documented that the resident opted to stay at the facility, indicating a preference to remain. On the day of transfer, the resident was placed in a wheelchair, taken onto the facility van with belongings, paperwork, and medications, and transported to the new facility. The Administrator stated that when the family member arrived and stopped the van, the resident made no indication they wanted to get off and proceeded to the new facility, although the resident later reported that they were taken to the new facility and that they wanted to go back to the original facility where they had friends. The Ombudsman reported that the family member notified their office of an appeal and that on 2/11/26 the facility’s SSD emailed the 30‑day discharge notice, which lacked the address of the receiving facility. The Ombudsman stated that an appeal hearing was scheduled for 4/2/26 and that the resident should have been allowed to return to the facility during the appeal process. The Administrator acknowledged that an email from the family member notifying the facility of the appeal was sent on 2/11/26 at 3:35 P.M., but it was not read until after the resident had already left on 2/12/26, and the resident was not allowed to return during the pending appeal.
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