The family's power of attorney learned about Resident 24's discharge only when another family member told her. She had received just one voicemail on Friday, August 8, about the resident's elopement and a possible move to a secure unit. No agreement was made to discharge him from the facility.
The resident had eloped from Avir at Kennedale and was considered high risk for future elopements. The facility's medical director approved the transfer to another facility but expected staff to notify the family before the resident left.
They didn't.
The facility's administrator discovered the communication breakdown after the fact. She stated she was upset at how the transfer was handled by the Director of Nursing and called it "a lack of communication." The administrator followed up with the family the day after the transfer, learning that the other facility was "a better fit for the resident."
The potential risk, according to the administrator, was the family not knowing where the resident had transferred.
Avir at Kennedale's own discharge policy, dated December 2017, states clearly: "It is the policy of this home that residents and/or responsible parties will be notified prior to transfer or discharge." The policy also requires documentation of all discharges and transfers in the facility's clinical software.
The violation represents a breakdown in basic communication protocols during what should have been a carefully coordinated transfer of a vulnerable resident. Federal inspectors found the facility failed to follow its own written procedures for notifying families before discharging residents.
Dementia patients who elope face significant safety risks, including injury, exposure to weather, and becoming lost. When such residents require transfer to more secure facilities, proper family notification becomes even more critical for continuity of care and family peace of mind.
The inspection report does not indicate how long the family remained unaware of their relative's location or what steps they took to locate him after discovering he was no longer at Avir at Kennedale.
The facility's administrator acknowledged the transfer was not handled appropriately, but the damage to family trust had already occurred. The resident's power of attorney had been left to piece together her relative's whereabouts through informal family communication rather than official notification from the facility responsible for his care.
This communication failure occurred despite the facility having established procedures specifically designed to prevent such situations. The written policy requiring prior notification of transfers exists precisely to avoid scenarios where families lose track of their vulnerable relatives during facility transitions.
The medical director's expectation that the family would be notified before discharge suggests the breakdown occurred at the operational level, where policy implementation failed despite clear administrative guidance.
Federal inspectors classified this as a violation causing minimal harm or potential for actual harm, affecting few residents. However, the impact on the affected family was significant, creating uncertainty about their relative's location and care during a vulnerable transition period.
The case highlights the critical importance of communication protocols in nursing home operations, particularly when dealing with residents who have cognitive impairments and safety risks. When facilities fail to follow their own notification procedures, families can be left scrambling to locate their relatives and ensure continuity of care.
The administrator's acknowledgment that she was "upset" about how the transfer was handled suggests internal recognition that proper procedures were not followed. However, this recognition came only after the family had already been left in the dark about their relative's whereabouts.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avir At Kennedale from 2025-09-03 including all violations, facility responses, and corrective action plans.