Failure to Notify Residents of Hospital Transfers
Penalty
Summary
The facility failed to provide timely written notification to residents and their representatives regarding transfers to the hospital. This deficiency was identified for eight residents who were transferred due to changes in their medical conditions. The clinical records for these residents did not contain documentation that the residents or their responsible parties were informed in writing about the transfers, the reasons for the transfers, or provided with Ombudsman information. The residents affected by this deficiency were transferred to the hospital on various dates throughout 2024. Despite the changes in their conditions necessitating these transfers, there was no evidence that the facility complied with the requirement to notify the residents or their representatives in writing. The facility's administrator confirmed during an interview that the required written notices were not provided, indicating a systemic issue in the facility's transfer notification process.
Plan Of Correction
1. Residents 39, 85, 89, 94, 143, 146, and 157, their responsible party, or legal representative were provided with the facility Transfer notice. 2. An initial audit will be completed by the NHA/Designee on residents that have been transferred out of the facility to an acute care facility since 12/10/24 to ensure their responsible party, or legal representative, was provided with the Transfer notice. 3. Licensed nursing staff will be re-educated on the Discharge/Transfer Policy and process by the DON and/or Designee. Residents transferred out of the facility will be reviewed at clinical meetings to ensure the RP has been provided with the transfer notice. 4. The NHA and/or designee will complete a random weekly audit x 90 days of Residents who have transferred to the hospital to ensure transfer notices were provided to them, their responsible party, or legal representative. Results of the audit will be reported to the Quality Assurance Performance Improvement Committee monthly.