Health inspection·December 27, 2023

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and interviews, the facility failed to notify a resident's family prior to a transfer to another facility. This affected one resident (#22) of four residents reviewed for resident rights. The facility census was 40. Findings included: Record review revealed Resident #22 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, respiratory failure, hypertension, schizoaffective disorder, hypothyroidism, dementia, dysphagia, anxiety disorder, and osteoarthritis. Review of a minimum data set (MDS) assessment completed on 12/04/23 revealed Resident #22 had moderately impaired cognition and was transferred to another facility on 12/04/23. Review of a discharge assessment completed on 12/04/23 revealed the discharge instructions were given to Resident #22. Review of nursing note from 11/30/23 at 8:09 P.M. entered by the Administrator revealed Resident #22's son was spoken with regarding a transfer to a new facility for behavior management, and son was agreeable to transfer as long as it was within three hours of his home. Review of a social services note from 12/04/23 at 3:00 P.M. revealed a voicemail was left to inform Resident #22's family the resident would be transferring to another facility. Review of a social services note from 12/05/23 at 9:00 A.M. revealed Resident #22's family was left another message requesting a return call. Review of a Transfer and Discharge log from December 2023 revealed Resident #22 was transferred to a facility in Xenia on 12/04/23. Review of the Transfer and Discharge Notice revealed Social Worker (SW) #102 reviewed the notice with Resident #22's representative. Interview on 12/27/23 at 12:19 P.M. with Resident #22's representative revealed he had been called days prior to the transfer to discuss potential other facilities but was given the impression he would be more involved in the process and have a chance to visit and approve the facility Resident #22 was sent to. The representative stated he was not aware Resident #22 had been transferred for a couple days and he had no idea where she had been transferred to. The representative denied having any missed calls or voicemails from the facility regarding Resident #22's transfer and stated he had left multiple voicemails for the administrator with no return call. The representative denied ever reviewing a Discharge or Transfer Notice with the facility. The representative stated when Resident #22 Page 1 of 2 365461 365461 12/27/2023 Muskingum Skilled Nursing & Rehabilitation 501 Pinecrest Drive Beverly, OH 45715

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few is off her medications, she is not able to make decisions because she is not lucid. The representative also stated Resident #22 was missing several of her belongings including an iPad. Interview on 12/27/23 at 1:54 P.M. with Registered Nurse (RN) #113 revealed she was not at the facility at the time of the discharge, but did hear Resident #22 was discharged without her family being notified and was told the transfer was due to increased behaviors. Interview on 12/27/23 at 2:03 P.M. with Licensed Practical Nurse (LPN) #187 revealed when Resident #22 was in a manic state, she was unable to make her own decisions. LPN #187 revealed she had not called Resident #22's family to notify them of the transfer to a new facility because she thought it was taken care of. LPN #187 also stated the facility had to tell Resident #22 she was going to Walmart to get her on the bus for the transfer. Interview on 12/27/23 at 3:00 P.M. with SW #102 revealed she was off work when Resident #22's discharge planning began and the administrator had taken care of sending a referral to the facility. SW #102 stated it was a hot mess because she was told at 3:00 P.M. on 12/04/23 Resident #22 would be discharging and she completed the discharge assessment. SW #102 stated she attempted to call family to notify them of the transfer and left a message. SW #102 stated she did fill out the Discharge/Transfer Notice and stated it was reviewed with family but did not ever actually talk to family apart from leaving a voicemail, but did not explain what the notice meant over the voicemail. SW #102 stated she thought someone else called, but was not able to determine who called so she just followed up. Interview on 12/27/23 at 3:09 P.M. with the Administrator revealed she did assist with the discharge planning while SW #102 was off work, which entailed calling the family to discuss reasons for potential transfer and sending referrals. Once the Administrator received an acceptance for Resident #22 from a facility, she relayed information to SW #102 so she could complete the transfer level of care and the discharge assessment. The Administrator stated the facility Resident #22 was accepted to was within the three hour limit her family requested. The Administrator stated SW #102 left messages for Resident #22's family and got ahold of them. The Administrator confirmed she did not call to notify Resident #22's family of her transfer and the resident was not able to make decisions in her current state of mind. The Administrator also confirmed she convinced Resident #22 to enter the bus for the transfer by stating they were going shopping. Review of a policy titled, Resident Rights Policy revealed all staff will be educated on resident rights at hire, during orientation, and annually. Review of a policy titled Admission, Discharge and Transfer Policy revealed the facility should assure sufficient preparation and orientation is provided to the resident for a safe and orderly transfer or discharge, the facility will inform the resident of their destination and transportation method, the resident should be actively involved to the extent possible in the selection process of the new residence, and all aspects of the transfer should be documented in the medical record including a resident or responsible party notification and the attending physician's orders. This deficiency represents non-compliance investigated under Complaint Number OH00149081. This deficiency is evidence of continued noncompliance from the survey dated 12/04/23. 365461 Page 2 of 2