Failure to Provide Written Notice for Resident Transfers
Penalty
Summary
The facility failed to comply with the regulatory requirements for notifying residents, their representatives, and the ombudsman in writing about transfers and the reasons for hospitalization. This deficiency was identified for four residents during a review of clinical records and staff interviews. The facility did not provide the required written notices for these transfers, which is a violation of the specified regulations. Resident 13, who was cognitively impaired and had diagnoses including heart failure and diabetes, was found on the floor with injuries and was transferred to the emergency room. There was no documented evidence of a written notice provided to the resident, their representative, or the ombudsman regarding this transfer. Similarly, Resident 23, who was cognitively intact but dependent on staff, was transferred to the hospital due to an inability to answer orientation questions, without the required written notice being documented. Resident 33, with mild cognitive impairment and mental health diagnoses, agreed to a hospital transfer for a mental health evaluation, yet no written notice was documented. Resident 37, who was cognitively intact and had multiple health issues, was transferred to the hospital on several occasions due to medical concerns, but again, no written notices were documented for these transfers. The Nursing Home Administrator confirmed the lack of written notices for these residents' transfers during an interview.
Plan Of Correction
Residents 13, 23, 33, and 37 were provided with notice of transfer. Ombudsman was notified of transfers for the months of January and February. Baseline audit was completed to identify residents that were transferred out of the facility during the months of January and February. A binder has been designated to maintain records of notice of transfer and Ombudsman notification. Education was provided to Social Worker and/or Designee on the process for maintaining records of notice of transfer and Ombudsman notification. Monitoring will be captured through auditing notice of transfer and Ombudsman notification of transfer. Up to 2 clinical records will be reviewed weekly for 4 weeks, then up to 4 clinical records 2 times monthly for 2 months. The audits will be conducted by the Social Worker or designee. Results of the audits will be provided to the Administrator and be presented for review at the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at QAPI Committee meeting.