Failure to Provide Timely Transfer Notices
Penalty
Summary
The facility failed to provide proper notice of transfer before initiating a transfer for two residents, which is a violation of the regulatory requirements. Resident #11 was admitted with multiple diagnoses, including acute failure, and experienced a change in condition that led to a recommendation for hospital transfer. The facility issued a Nursing Home Transfer and Discharge Notice after the transfer, which was signed by the Social Service Director and the resident post-transfer, indicating a lack of timely notification. Resident #60 was transferred to an acute care facility for a medical procedure, but the Nursing Home Transfer and Discharge Notice was not completed with all required information. The notice lacked a brief explanation to support the transfer action and did not include the resident representative's information. The notice was signed by the resident after the transfer, which suggests that the facility did not provide the notice in advance as required. Interviews with facility staff, including the Nursing Home Administrator and the Social Services Director, revealed a misunderstanding or misapplication of the notice requirements, particularly in emergency situations. The facility's policy on transfer and discharge notice was not followed, as evidenced by the delayed completion and signing of the notices. This deficiency highlights the facility's failure to adhere to federal regulations regarding timely and complete notification of transfers or discharges.
Plan Of Correction
The facility is unable to have residents #55, #60 and #11 sign the Nursing Home Transfer and Discharge Notice at the time of discharge to the hospital since the date of their discharge has passed. Residents #55, #60 and #11 were re-admitted and/or returned to the facility after their emergency discharge to the hospital. Other residents discharged after will receive the Nursing Home Transfer and Discharge Notice based on the facility policies. The facility policy for Notice of Transfer and/or Discharge was reviewed. On the Director of Nursing/designee initiated education for the nurses, Assistant Director of Nursing, Social Service Director and Medical records related to the facility Notice of Transfer and Discharge policy and Making an Emergency Transfer or Discharge policy. The education included the Nursing Home Transfer and Discharge Notice form. This education was completed by The Social Service Director/designee will do a weekly audit for 12 weeks on a minimum of 3 discharged residents each week. Otherwise, if the facility doesn't have at least 3 discharges per week, the Social Service Director/designee will complete the weekly audit on the number of discharges the facility has for that week. This weekly audit will be done to ensure that the facility provided discharged residents the Nursing Home Transfer and Discharge Notice form per the facility policy. The Social Service Director or designee will review the audits with the monthly Quality Assurance Performance Improvement Committee for three months. The Quality Assurance and Performance Improvement Committee will evaluate the outcome of the audits and if necessary, amend the improvement plan and continue to monitor until substantial compliance has been determined by the committee.