Deficiency in Transfer and Discharge Notifications
Penalty
Summary
Yardley Rehabilitation and Healthcare Center was found to have a deficiency related to the requirements for notice before transfer or discharge of residents. The facility failed to provide a 30-day advanced written notice of discharge to the resident's representative, as required by federal regulations. Specifically, Resident 1 received a revised discharge notice that was not communicated to the responsible party or legal representative in writing, as confirmed by the facility's Administrator. Additionally, the facility did not provide written notifications to residents or their representatives regarding hospital transfers. Residents 2, 3, and 4 were transferred to the hospital following changes in their conditions, but there was no documentation to support that these transfers were communicated in writing to the residents or their responsible parties. This lack of documentation was confirmed during an interview with the Administrator. The facility's policy, last reviewed on January 7, 2025, required that residents and their representatives receive a 30-day advanced written notice for planned transfers or discharges, as well as a transfer notice for hospitalizations. However, the facility failed to adhere to this policy, resulting in a deficiency related to the notice requirements before transfer or discharge.
Plan Of Correction
1. Resident 1, 2, 3 and 4 have had written notification provided to responsible party or legal representative regarding transfer to hospital and pending discharge. 2. A 7 day look back audit was completed to validate written notifications to responsible parties or legal representatives and resident are provided for hospital transfers to hospital and center initiated pending discharges. 3. Nurse supervisors and management are re-educated on written notifications being provided to responsible party or legal representative and resident regarding transfer to hospital and pending discharge due to center initiated discharge. 4. NHA/Designee will complete random weekly audits x4 weeks then monthly x2 to validate written notifications are provided. Audit findings will be submitted to the Quality Assurance Performance Improvement Committee monthly for further review and recommendations as needed. Further audit frequency will be determined based on the outcome of the previously completed audit findings.