Failure to Provide Written Notice for Hospital Transfer
Penalty
Summary
Lakewood Rehabilitation and Healthcare Center was found to be non-compliant with the requirements of 42 CFR Part 483 Subpart B, specifically regarding notice requirements before transfer or discharge. The facility failed to provide a written notice for a facility-initiated transfer to the hospital for one resident. This notice should have included the reason for the transfer in a language and manner easily understood by the resident and their representative. The deficiency was identified during a survey conducted on December 30, 2024, which reviewed clinical records and included staff interviews. The specific incident involved a resident who was transferred to the hospital on December 29, 2024, due to a change in mental status. The clinical record indicated that the transfer was initiated by the facility, but there was no evidence of a written notice being provided to the resident or their representative. This lack of documentation and communication was a key factor in the facility's failure to meet the regulatory requirements for notice before transfer or discharge.
Plan Of Correction
1. The facility has provided Resident 2/resident representative with the facility transfer notice via certified mail. 2. The facility has reviewed resident's transfers and discharges for the past 14 days to ensure the notice of transfer has been provided. 3. DON/designee will re-educate licensed nursing staff to the facility process of notifying residents/resident representatives on facility transfers. 4. DON/designee will audit random resident transfers and discharges to ensure a written notice and the reason for transfer has been provided. Audits to be completed weekly for four weeks and monthly for two months. Audits to be submitted to QAPI for review and recommendations.