Failure to Notify of Hospital Transfer
Penalty
Summary
The facility failed to provide timely written notification to a resident, their responsible party, and the Ombudsman regarding the reason for the resident's transfer to the hospital. This deficiency was identified during a review of clinical records and staff interviews. The resident in question was cognitively intact and required assistance for daily care needs, as indicated by a quarterly Minimum Data Set assessment. On October 12, 2024, the resident experienced a large, liquid, and brown emesis, prompting the physician to be notified and the resident to be transferred to the hospital. However, there was no documented evidence that a written notice of the transfer was provided to the resident's responsible party or the Ombudsman. The Director of Nursing confirmed the lack of written notification during an interview on December 10, 2024.
Plan Of Correction
1. The facility cannot retroactively address the transfer to the hospital. Resident 24 returned to the facility after their hospitalization. No residents have been refused re-admission to the facility. 2. The Interdisciplinary team will review hospital transfers during morning clinical meetings to make sure the resident/responsible party received written notice that includes the reason for transfer. The Social Service Director or designee will complete missed forms upon discovery. 3. RN Supervisors including agency, Social Services, and Case Manager will be educated on the facility's policy for written notification that includes the reason for the transfer at the time of transfer. 4. The Administrator or designee will audit hospital transfers weekly for four weeks, then monthly for two months for documentation providing written notifications with the reason for hospitalization. Identified issues will be addressed when found. Results of this audit will be reviewed by the Quality Assurance and Improvement Committee for additional recommendations if necessary.