Failure to Notify POA and Document Discharge Planning for Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to notify and involve a resident’s activated Power of Attorney for Healthcare (POAHC) in the discharge and transfer process, and the absence of required discharge documentation, including a recapitulation of stay. The resident had vascular dementia, diabetes, and right-side paralysis from a cerebral infarction, with a BIMS score of 5/15 indicating severely impaired cognition, and an activated POAHC to assist with medical decisions. The facility’s admission agreement stated that all transfers or discharges would comply with federal and state regulations, that discharges would occur only under specified procedures, and that the facility would provide preparation and orientation involving the resident and representative in discharge planning and post-discharge care arrangements. Despite this, the resident was transferred to another skilled nursing facility via transportation service, with no family or POAHC present, and without documented involvement of the POAHC in discharge planning. Record review showed a physician-signed discharge order, but the section for the resident or resident representative signature was blank, and there was no documentation of discharge communication or a recapitulation of stay in the medical record. The POAHC reported not being included in any discharge planning meetings, not initiating the transfer, and not being informed of any potential transfer during the months preceding the move; the POAHC only learned of the transfer after it had already occurred and did not receive or sign any transfer paperwork. The Social Services and Admission/Discharge Coordinator acknowledged that they are responsible for working with the resident or representative during discharge planning, ensuring care plan updates, obtaining signatures, and documenting communication, but confirmed that they did not contact the POAHC, did not obtain the POAHC’s signature, and that the record lacked discharge communication. The Nursing Home Administrator acknowledged that the discharge process for this resident did not occur in accordance with facility policy.
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