Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to residents and their responsible parties regarding the reasons for hospital transfers, as required by regulations. This deficiency was identified for five residents during a review of clinical records and staff interviews. The facility did not document the reasons for the transfers in writing, nor did they notify the residents' responsible parties, which is a violation of the notice requirements before transfer or discharge. Resident 28, who was cognitively intact and dependent on staff for daily care, was transferred to the hospital without written notification to the responsible party. Similarly, Resident 39 was admitted to the hospital with a urinary tract infection, and there was no documented evidence of written notice provided. Resident 40, who was cognitively impaired and required maximum assistance, was sent to the hospital following a fall, but again, no written notice was given to the responsible party. Resident 48, who had multiple diagnoses including a hip fracture and dementia, was transferred to the hospital twice due to worsening kidney function, yet no written notice was provided. Lastly, Resident 69, who had cancer and other conditions, was sent to the hospital due to ostomy issues, but there was no documented evidence of written notification to the resident or their responsible party. Interviews with facility administrators confirmed the lack of written notices for these transfers.
Plan Of Correction
Residents 69 and 48 have since been discharged from the facility. Residents 39, 28, and 40 have not been sent out of the facility since findings. A sweep of all resident transfers was conducted to ensure there was documentation evidence of written notice to the resident's responsible party regarding the reasoning for the transfer from the facility. All issues discovered were corrected at the time of discovery. The navigation team was re-educated on written notice to the resident's responsible party when a transfer is facility-initiated. The Nursing home administrator (NHA) or designee will conduct audits to ensure all facility-initiated transfers have documented written notice to the responsible party regarding the reason for transfer weekly X4 weeks, then monthly X2 month. Identified issues will be addressed at the time of discovery. Audit results are reported to the Quality Assurance Performance Improvement committee to identify trends and further opportunities for quality improvement and needs for additional education/re-education.