Inadequate Transfer Notices for Hospitalized Residents
Penalty
Summary
The facility failed to provide adequate notice of transfer for three residents who were hospitalized. The deficiencies were identified through clinical record reviews, facility document reviews, and staff interviews. The residents involved had serious medical conditions, including atrial fibrillation, acute kidney failure, chronic diastolic congestive heart failure, and chronic respiratory failure with hypoxia. These conditions necessitated their transfer to a hospital. The facility's document titled 'Notice of Proposed Involuntary Discharge or Transfer' was found lacking in several required elements. Specifically, the notices did not include the location of transfer, a statement of the residents' appeal rights, or the mailing addresses of the entities responsible for receiving appeal requests. Additionally, the notices omitted the mailing addresses for the Office of the State Long-Term Care Ombudsman and the agencies responsible for the protection and advocacy of individuals with developmental disabilities and mental disorders. During an interview, the Nursing Home Administrator confirmed that the facility's transfer notices did not contain all the required information. This oversight affected three residents who were transferred to the hospital, as their notices were incomplete and did not comply with the regulatory requirements for transfer or discharge notifications.
Plan Of Correction
1. The involuntary transfer notification form cannot be recreated for (Residents 47, 50, and 58) who received it. The involuntary transfer/discharge form has been updated to include the required elements. 2. The Director of Operations/designee has provided education to the NHA and DON on the correct formatting of this notification. An audit was completed for involuntary Transfer/Discharges starting March 1, 2025. Of these 12 involuntary transfers, 3 remain in the hospital and will receive the corrected form listing the address and phone number of the entity which receives request for appeal along with PA State Long Term Care Ombudsman, Advocacy Agency for Intellectual or Developmental Disability and Advocacy Agency for Mental Disorder or Related Disability addresses and phone numbers. 3. An audit will be conducted weekly x 4 of involuntary transfer/discharge notifications to ensure that the proper form is used for these instances. 4. Results of the audit will be taken to QAPI for review of findings and further interventions if indicated.