Failure to Provide Written Notice for Hospital Transfers
Penalty
Summary
The facility failed to provide written notice to the responsible parties of three residents regarding their transfers to the hospital, which is a requirement under §483.15(c)(3)-(6)(8). Resident 12, who was cognitively intact, was found on the floor with confusion, tremors, and hyperventilation, leading to a hospital transfer. However, there was no documented evidence that a written notice was provided to the resident's responsible party explaining the reason for the transfer. Resident 32 experienced a change in condition, including lethargy and disorientation, prompting a transfer to the emergency department for further evaluation. On a separate occasion, the resident requested to go to the emergency department due to shortness of breath. In both instances, there was no documented evidence that a written notice was provided to the responsible party regarding the reasons for the hospital transfers. Resident 84 was found on the floor with a laceration and bleeding, necessitating a hospital transfer for evaluation. Again, there was no documented evidence that a written notice was provided to the responsible party regarding the reason for the transfer. Interviews with facility staff confirmed the lack of documentation for the required written notices for all three residents.
Plan Of Correction
Preparation and submission of this POC is required by state and federal law. This Plan Of Correction (POC) does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. The facility could not go back and notify Resident #12, Resident #32, or Resident #84 of their immediate transfer/discharge from the facility in written notification. To identify other residents with the potential to be affected, the Director of Nursing/designee will audit residents who had an immediate transfer/discharge within the last two weeks to see if the written notification to responsible parties was completed. To prevent a future occurrence, the Director of Nursing/designee will educate nursing staff/social service department on the immediate transfer/discharge paperwork to ensure that families and responsible parties moving forward are notified in writing of the transfer from the facility. To monitor and maintain ongoing compliance, the Director of Nursing/designee will complete an audit of weekly hospital transfers to ensure written notifications to responsible parties were completed weekly x4 and then monthly x2. Results of audits will be forwarded to facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations.