Failure to Provide Required Transfer Notifications
Penalty
Summary
The facility failed to provide timely written notification to residents and their responsible parties regarding transfers to the hospital, as required by regulations. This deficiency was identified for five residents, who were transferred to the hospital due to changes in their conditions. The clinical records for these residents did not contain documentation of written notifications that included necessary information such as the reason for transfer, effective date, location, appeal rights, and contact information for the State Ombudsman and advocacy agencies. The Nursing Home Administrator confirmed that the facility did not provide the required written notices and had not submitted any transfer notices to the State Ombudsman for several months until after the survey process highlighted the issue. Specific cases included Resident 59, who was transferred on December 1, 2024, without the required written notification. Resident 91 and Resident 98 were also transferred without proper notification, and the State Ombudsman was not informed in a timely manner. Resident 63 experienced two hospitalizations, and in both instances, neither the resident nor the resident's representative received the required written notices. The facility was unable to provide evidence of compliance with notification requirements during interviews with the surveyor, indicating a systemic issue in adhering to regulatory standards for resident transfers.
Plan Of Correction
1. Facility cannot retroactively correct transfer notification to residents 59, 63, 91, 18, and 98. 2. Business office manager/designee completed an audit of the last month of discharges and any missed transfer notifications were addressed. 3. Nursing staff will be re-educated on providing notification to residents and resident representatives upon transfer out of the facility. 4. DON/designee will conduct random audits of transfers to verify proper notification weekly x4 and monthly x3. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.