Deficiencies in Transfer Notice Compliance
Penalty
Summary
The facility failed to comply with the notice requirements before transferring or discharging residents, as outlined in 42 CFR Part 483, Subpart B. Specifically, the facility did not provide adequate notice of transfer for two residents who were hospitalized, and the notices for five other residents lacked required information. The deficiencies were identified during a review of clinical records and staff interviews. Resident 1, diagnosed with heart failure, chronic kidney disease, and hyperlipidemia, was transferred to the hospital due to an acute medical change. The notice provided to Resident 1's representative was missing several required mailing addresses, including those for the entity receiving appeal requests and the Office of the State Long-Term Care Ombudsman. Similar deficiencies were found in the notices for Residents 28, 52, 58, and 69, who were also transferred to hospitals for various medical conditions, including dementia, hypertension, and heart failure. Additionally, Resident 28's clinical record lacked a notice of transfer for one of their hospitalizations, and Resident 53's record showed no evidence of a transfer notice being provided for a hospital evaluation following a fall. Interviews with the Nursing Home Administrator and Director of Nursing confirmed the absence of required information on the transfer notices and the failure to provide proper documentation for some transfers.
Plan Of Correction
1. Unable to retroactively correct the clinical record for Residents 1, 28, 52, 53, and 58 with a notice upon transfer that included required and revised information. All residents continue to reside at the facility. R69 no longer resides at the facility, no adverse effects related to practice. 2. All residents have the potential to be impacted. R1, R28, R52, R53, and R58 will be given the revised Transfer or Discharge form with the appropriate notice of information no later than March 14, 2025 for any immediate Transfer or Discharge, along with a facility-wide audit conducted by the DON and Shift Supervisors. 3. DON will educate the Shift Supervisors by March 14, 2025 upon emergent transfer to the hospital and will provide the revised Notice of Resident Transfer or Discharge form to resident and document in a progress note via the EHR system (PCC) to reflect it was presented with appropriate information. The Shift Supervisor is to then complete a progress note documenting the notice was provided and to whom. The DON will also educate Shift Supervisor on the updated Notice of Resident Transfer on Discharge form, and to provide the Notice of Resident Transfer to Discharge Form to the Resident revealing the mailing address of the entity, which receives request for appeals, mailing address of the Office of the State Long Term Care Ombudsman for protection and advocacy of individuals with developmental disabilities and mental disorders. The DON will in-service the Shift Supervisors by March 14, 2025 to ensure the representative is provided the notice and signed the form when received. DON will also educate the Social Worker by March 14, 2025 to send a 30-day log of transfer and discharges to the local Ombudsman's email box. 4. Social Worker Director and DON will conduct a record audit via the progress notes of all residents who have emergent transfer to the hospital and audit the transfer and discharge log to be sent to the Ombudsman daily x 3 to ensure the Notice of Residents Transfer or Discharge information contained appropriate information and was given and signed appropriately, to whom until 100% completion is achieved. Audits will continue x2 weekly, until 100% is achieved. Findings of the audits will be reported monthly to the QAPI committee meeting to ensure compliance is obtained and maintained.