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, including the reasons for the transfers and information about the Ombudsman. This deficiency was identified for three residents who were transferred to the hospital due to changes in their conditions. Resident 11 was transferred on October 12, 2024, after a change in condition, Resident 13 was transferred on December 11, 2024, following a fall and change in condition, and Resident 56 was transferred on November 4, 2024, after a change in condition. In each case, there was no documentation to support that the residents or their representatives received the required written information. The Administrator confirmed in an interview that the written notices were not provided.
Plan Of Correction
Resident 11 and 56 no longer reside in the facility. Unable to retroactively correct for resident 13. All residents have the potential to be affected by this alleged deficient practice, however the facility cannot retroactively correct. DON & NHA will be educated on the components of this regulation with emphasis on the need to provide written notification of transfers. NHA or designee will audit 3 hospital transfers to ensure written notification was completed. Audit will be conducted 2x a week x 4 weeks then, 1x a week x 4 weeks then, 2x a month x 2 months then, 1x a month x 2 months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings during QAPI.