Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide written notification of transfer or discharge to the hospital for five residents, as required by their policy and regulations. Residents involved had varying levels of cognitive impairment and required assistance with activities of daily living. For instance, one resident with intact cognition and dependent on staff for all activities was transferred to the hospital due to respiratory issues, but there was no documented evidence of written notification to the resident or their representative. Similarly, other residents with moderately impaired cognition were transferred to the hospital without documented written notice being provided. The Director of Social Work acknowledged the lack of documented evidence for providing written notices, attributing it to a service gap caused by recent administrative changes. The facility's Administrator, who had recently started, identified the issue during an audit and noted that the facility had not been issuing discharge notices in writing for some time. This deficiency was recognized as a result of new staff and changes in administration, which led to a lapse in following the established procedure for notifying residents and their representatives in writing about transfers or discharges.
Plan Of Correction
Plan of Correction: Approved April 4, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Element #1: The following actions were accomplished for the resident(s) identified in the deficient practice: ò Review of identified residents revealed that Residents #50, 69, 68 experienced transfers to the hospital and all were readmitted to the facility after completion of acute hospital stay and are current residents. Resident #202 was transferred to the hospital for acute needs and expired in the hospital. Resident #203 was scheduled for discharge to ALF prior to hospital admission and was directly discharged to ALF from acute care hospital. ò Education provided to social workers on the requirement for notice of transfer/discharge to accompany all residents transferred/discharged from the facility. Element #2: The following actions will be implemented to identify other residents who have the potential to be impacted by the deficient practice: ò All residents who were transferred/discharged had the potential to be affected, however no residents were negatively impacted. ò An audit of past 30 days of discharges was conducted to ensure Notice of Transfer/Discharge was provided and to ensure the resident or the resident's representative were notified in writing of the reason for transfer/discharge to the hospital in a language they understood and to notify the Ombudsman for discharge or transfer and hospitalization. Negative findings will be immediately corrected. Element #3: The following system changes will be implemented to prevent reoccurrence: ò The facility policy and procedure on 'Discharge Notice' was reviewed and found to be appropriate. ò Social Work staff, medical records and licensed nursing staff will be reeducated on the facility policy and requirement for discharge/transfer notification for all residents and a record of education will be maintained for reference and validation. Element #4: The facility’s compliance with the corrective action will be monitored using the following quality assurance system: ò The Director of Social Work has created an audit tool to ensure that Notice of Transfer/Discharge documentation is accurately completed for all planned and unplanned discharges and validate that all required documentation is uploaded to the facility eMAR system. ò The Director of Social Work/designee will audit, and audits will continue until 100% compliance is attained for 4 consecutive weeks. Negative findings will be corrected immediately and reported to the administrator. ò Results of audits will be reviewed during monthly QAPI meetings and the QAPI committee will determine ongoing audit frequency after three months of compliance. Element #5: The person responsible for the corrective action is the Director of Social Work/designee. Date of Compliance is [DATE].