Failure to Provide Written Notices for Hospital Transfers
Penalty
Summary
The facility failed to provide written notice regarding emergency transfers to the hospital to the Office of the State Long-Term Care Ombudsman, as well as to the residents and/or their responsible parties. This deficiency was identified for five residents during the review. The lack of documentation of these notices was confirmed through clinical record reviews and staff interviews. Resident 1, who was cognitively intact, experienced chest pain on two occasions and requested to be sent to the hospital. Despite being admitted with congestive heart failure, there was no documented evidence that the required written notices were provided. Similarly, Resident 29, who was sometimes understood, was transferred to the hospital following a fall and was later admitted for altered mental status, but again, no written notices were documented. Resident 35, who was sometimes understood, was transferred to the hospital for a CT scan and admitted for an acute head injury with bleeding, yet no written notices were provided. Resident 54, who was severely cognitively impaired, experienced falls and changes in condition leading to hospital transfers, but lacked documented notices. Lastly, Resident 59, who was moderately cognitively impaired, was transferred to the hospital following a fall and subsequent admission, with no evidence of written notices being provided.
Plan Of Correction
The facility cannot retroactively correct this deficiency. Residents discharged via emergency transfer have the potential to be affected by this deficient practice. The facility is initiating a notice of discharge or transfer policy. This will include notifying residents or their responsible parties in writing about the reason for the emergency transfer. Nursing staff will receive mandatory training by the Director of Nursing or designee on the new policy, and the Social Services department will oversee the process to ensure compliance. The social services director will resume monthly notification to the Office of Long-term Care Ombudsman. All transfers and discharges will be audited by the administrator for 4 weeks. Audits will be reviewed by the Quality Assurance Performance Improvement committee for results, areas of improvement and/or continued auditing.