Lack of Hospital Transfer Agreements
Summary
The facility failed to ensure that written transfer agreements with hospitals were in place to guarantee timely hospital admissions for residents when medically necessary. This deficiency was identified through interviews and record reviews, revealing that the facility did not have any transfer agreements with hospitals, nor could they provide a policy on transfer agreements. During an interview, the Administrator and the Assistant Director of Nursing (ADON) acknowledged that the corporate Quality Assurance Registered Nurse was unable to locate any transfer agreements with hospitals. The Administrator admitted to having no knowledge of any existing transfer agreements. This oversight had the potential to affect all 40 residents of the facility.
Penalty
Resources
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The facility did not have transfer agreements with hospitals certified by Medicare or Medicaid, potentially affecting all 99 residents. The facility only had agreements to transfer residents to sister facilities in emergencies. Interviews confirmed that a written transfer agreement was not executed until late August, indicating a failure to ensure timely hospital transfers for residents.
The facility failed to have an updated and signed transfer agreement in place to accommodate residents in the event of an emergency. This affected 10 ventilator-dependent residents and had the potential to affect all 86 residents residing in the facility. The transfer agreement was last updated in July 2020 and was not signed by the local hospital listed in the agreement.
Lack of Transfer Agreements with Hospitals
Penalty
Summary
The facility failed to ensure that transfer agreements with hospitals certified by Medicare or Medicaid were in place, which had the potential to affect all 99 residents residing in the facility. A review of the facility's 2024 Tabletop Disaster Drill document revealed that the facility had agreements to transfer residents to two sister facilities in the event of an emergency. However, it was confirmed through interviews with the Director of Nursing and the Administrator that a written transfer agreement was not executed until August 26, 2024. Prior to this date, the facility did not have a transfer agreement in place, which was a requirement to ensure residents could be moved quickly to a hospital when they needed medical care.
Lack of Updated and Signed Transfer Agreement
Penalty
Summary
The facility failed to have an updated and signed transfer agreement in place to accommodate residents in the event of an emergency. This deficiency affected 10 ventilator-dependent residents and had the potential to affect all 86 residents residing in the facility. The facility utilized mechanical Ventilation, Oxygen, Cough, Suction, and Nebulizer (VOCSN) therapies with a total of up to 22 hours of battery backup per ventilator. During a document review, it was found that the transfer agreement was last updated in July 2020 and was not signed by the local hospital listed in the agreement. The Administrator confirmed the outdated and unsigned status of the transfer agreement during the review.
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