Failure to Provide Written Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide timely and appropriate written notifications of transfer or discharge to residents, their representatives, and the Office of the State Long-Term Care Ombudsman. This deficiency was identified during a recertification survey, affecting two residents. Resident #6, who had moderate cognitive impairment and was readmitted with diagnoses including fracture and malnutrition, was transferred to the hospital due to skin irritation and foul odor from a splint. However, there was no documented evidence that a written notice of this transfer was provided to the resident, their representative, or the Ombudsman. Similarly, Resident #12, who also had moderate cognitive impairment and was admitted with conditions such as dementia and diabetes, was discharged home with only a verbal consent from the resident's representative. The written notice of discharge was dated just one day before the actual discharge and lacked signatures and mailing information to the designated representative, Ombudsman, or family member. The facility's failure to provide these notices was confirmed through interviews with the residents' representatives and Ombudsman staff, who reported not receiving the necessary documentation. Interviews with facility staff, including the Director of Social Work, Registered Nurses, and the Administrator, revealed inconsistencies and misunderstandings regarding the process for issuing and documenting transfer and discharge notices. The facility's policy required that such notices be sent to the Ombudsman and provided to residents and their representatives, but there was no evidence that this was consistently done. The staff interviews highlighted a lack of coordination and clarity in responsibilities, contributing to the deficiency in notifying the appropriate parties about resident transfers and discharges.
Plan Of Correction
Plan of Correction: Approved February 27, 2025 This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. 1) Immediate actions taken for those residents identified: Resident #6 has since returned to the facility. Resident #12 was discharged to the community with the Discharge/Transfer forms containing the Ombudsman information. Both Resident Families were notified about all the pertinent information with regards to the Ombudsman office. Written Notices for transfer and discharges for Resident #6 and Resident #12 were forwarded to the Office of the State Long-Term Care Ombudsman. 2) How the facility identified other residents: All residents can be affected by this deficient practice. The Director of Social Services or Designee audited the residents transferred/discharged to ensure Notice of Discharge/Transfer were issued and were communicated with the Ombudsman Office. As a result of the Audit completed by Director of Social Services, no other Residents were affected. 3) Measures put into place/System changes: Transfer and Discharge Notice Policy was reviewed and kept the same. Licensed Nursing Staff and Social Services will be re-educated by Nurse Educator regarding completing the Notice of Transfer/Discharge upon Planned Discharges and upon Emergency Transfers and instructed to keep a copy for facility records. Social Services shall email a copy of the notices to the Ombudsman Office. Social Services shall mail a copy of the notices to the Resident Representative after the transfer/discharge as an additional measure. 4) How the corrective actions will be monitored: An Audit tool was developed on monitoring compliance with communication with the Ombudsman Office. The Social Service Director or Designee shall be responsible for oversight of these audits. The Social Service Director or Designee will ensure that all the steps stated in all the elements are implemented. Every week for a year, the Director of Social Services or Designee will audit all discharges/transfers to ensure compliance. The results of these audits will be presented to the quarterly QAPI meeting.