Failure to Timely Process Resident and Family Request for Transfer to Memory Care
Penalty
Summary
The deficiency involves the facility’s failure to provide timely assistance with a resident and family-initiated request for discharge and transfer to another facility with a memory care unit. The resident, who had multiple diagnoses including type 2 diabetes, dementia, nutritional deficiency, acute kidney failure, transient ischemic attack, and atherosclerotic heart disease, had a BIMS score of eight indicating cognitive impairment but was largely independent with personal care and ADLs. On one date, an LPN documented that the resident stated she was supposed to move to another facility that day, but there were no transfer or discharge orders, and the resident became agitated and required redirection. A subsequent progress note documented that the social service worker spoke with the resident’s daughter/guardian, who requested a transfer to a facility with a memory care unit and stated that a referral had been sent. Further review showed that on a later date the Admissions Director spoke with the resident’s daughter, who was also power of attorney, and the daughter again requested referrals to facilities with memory care units. The Admissions Director emailed the Senior Social Worker listing five specific facilities and documented that the daughter wanted referrals sent to those facilities; the Senior Social Worker replied that she would take care of the referrals by the end of that business day. A follow-up email from the Admissions Director several days later requested an update, and the Senior Social Worker responded that she would be in the building on Tuesday and referenced having state in three facilities and things being “a little crazy.” Interviews revealed conflicting accounts: the former social service worker stated he sent a referral on the same day he was terminated; the Senior Social Worker stated she told the Admissions Director to send the referrals; and the Admissions Director stated she was told the Senior Social Worker would send them and verified that only one referral had actually been sent. This sequence of miscommunication and lack of follow-through on the resident/family’s transfer request was inconsistent with the facility’s discharge planning policy, which required safe, person-centered, and compliant discharge planning in collaboration with the resident, representative, and interdisciplinary team.
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