Failure to Provide Written Notice for Hospital Transfers
Penalty
Summary
The facility failed to provide a written notice regarding emergency hospital transfers to the State Long-Term Care Ombudsman, the residents, and their responsible parties for two residents. Resident 61, who was cognitively intact, experienced symptoms such as sweating, slurred speech, and hypoxia, followed by vomiting brown liquid, which led to an emergency room transfer. There was no documented evidence that the required written notices were provided to the relevant parties regarding this transfer. Similarly, Resident 73, who was also able to understand and be understood, was transferred to the hospital after being found with low blood pressure, pale and clammy skin, and only responding to physical stimuli. Despite the physician's order for hospital transfer, there was no documented evidence that the required written notices were provided to the State Long-Term Care Ombudsman, the resident, or the resident's responsible party. The Director of Nursing confirmed the absence of such documentation for both residents.
Plan Of Correction
1. The identified concern for R61 and R73 cannot be corrected. 2. The Director of Nursing or designee will audit the last three months of long term hospital transfers for notification that a written notice for transfer to the hospital was provided to the State Long-Term Care Ombudsman and that a written notice was provided to the resident and the resident's responsible party regarding the reason for transfer to the hospital for long-term residents. 3. The Director of Nursing or designee will re-educate staff on the process of notification to the State Long-Term Care Ombudsman and providing a written notice to the resident and or resident's responsible party regarding the reason for transfer to the hospital for long-term residents. 4. The Director of Nursing or designee will audit the process of notification to the State Long-Term Care Ombudsman and providing a written notice to the resident and or resident's responsible party regarding the reason for transfer to the hospital for long-term residents. The audits will be conducted weekly x4 and monthly x2. All findings will be submitted to the Quality Assurance Committee.