Failure to Provide Required Transfer Notifications
Penalty
Summary
The facility failed to provide the required written notification to a resident and their responsible party regarding a transfer to the hospital. For Resident 4, there was no documentation of written notification to the resident's responsible party about the transfer, which should have included the reason for the transfer, the effective date, the location, and a statement of the resident's right to appeal, among other required details. This deficiency was confirmed during an interview with a registered nurse supervisor. For Resident 13, the facility did not provide the resident's husband with the necessary written notice of the transfer to the hospital. Although a Notice of Transfer or Discharge was dated the day after the transfer, there was no evidence that the resident's husband received this notice, as the signature line for acknowledgment was blank. The resident's husband, who frequently visits the facility, could not recall receiving such a notice. The surveyor discussed these findings with the Nursing Home Administrator and the Director of Nursing, confirming the lack of compliance with the required notification process for both residents. The facility's failure to provide proper written notification for hospital transfers was identified as a deficiency in meeting the regulatory requirements for resident rights and notice requirements before transfer or discharge.
Plan Of Correction
1. The facility can not retroactively correct deficient practice. 2. The facility reviewed any resident transfers from the past 30 days to determine if any other residents or responsible parties were missing written notification of hospital transfers. Any identified deficiencies were immediately corrected. 3. NHA educated Social Services who received re-education on proper hospital transfer notification procedures, including: - The required elements of written notification. - Timely distribution and documentation of notifications. - The resident's right to appeal and required contact information for relevant agencies. - Ensuring responsible parties receive and acknowledge the notification. 4. The NHA and or designee will audit up to 5 random hospital transfers per month for three months to verify that: - Written notifications were completed. - All required elements were included. - Documentation was properly signed and acknowledged by the responsible party and if unable to get signature proof of mailed documentation was provided. Audit results will be reviewed by the QAPI team monthly to determine the need for ongoing monitoring.