Failure to Provide Written Transfer Notices
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].
Penalty
The facility did not issue written transfer or discharge notices to two residents or their legal representatives before transferring them to an acute care hospital. Documentation for both cases lacked evidence of the required notifications, and this was confirmed by the Market Clinical Advisor during the survey.
Facility staff did not provide required notifications to the ombudsman or written notices to residents and their representatives during transfers or discharges to hospitals. In several cases, residents with varying levels of cognitive impairment were transferred without proper documentation or notification, and staff interviews revealed a lack of awareness of these requirements.
A resident was transferred to the hospital for evaluation of shortness of breath, but the facility did not notify the ombudsman as required. The NHA stated they were unaware of the notification requirement, and this deficiency was identified through interviews and record review.
The facility did not notify the State Long-Term Care Ombudsman of hospital and ED transfers for two residents, as required by policy. One resident's hospital transfer and another resident's two ED transfers were omitted from the monthly reports, with staff confirming these events were not reported due to oversight and lack of awareness of notification requirements.
A resident with End Stage Renal Disease and Dependence on Renal Dialysis was transferred to the hospital and later returned, but the transfer was not documented in the Emergency Transfer Log or reported to the State LTC Ombudsman as required. Both the Social Service Director and Administrator confirmed the omission during interviews and record reviews.
Staff did not provide written notification to a resident and their representative upon the resident's transfer to the hospital, instead relying solely on verbal communication as confirmed by both an RN/Unit Supervisor and an LPN.
Failure to Provide Written Transfer/Discharge Notices Prior to Hospital Transfers
Penalty
Summary
The facility failed to provide written transfer or discharge notices to residents or their legal representatives prior to facility-initiated transfers to an acute care hospital. Specifically, documentation for two residents showed that each was transferred and subsequently admitted to a hospital, but there was no evidence in their clinical records that a written notice of transfer or discharge was issued to them or their legal representatives. This deficiency was confirmed during an interview with the Market Clinical Advisor, who was unable to locate the required transfer/discharge forms for these residents at the time of their transfers.
Failure to Notify Ombudsman and Provide Written Transfer/Discharge Notices
Penalty
Summary
Facility staff failed to provide timely and appropriate notification to residents, their representatives, and the Office of the State Long-Term Care Ombudsman prior to or at the time of transfer or discharge for multiple residents. In several cases, there was no evidence that the ombudsman was notified when residents were transferred to local hospitals or higher levels of care. Staff interviews revealed a lack of awareness regarding the requirement to notify the ombudsman, and documentation supporting such notifications was not provided to surveyors upon request. For one resident with intact cognition, there was no documentation that the ombudsman was notified of the resident's transfer to a hospital. Another resident, who was severely cognitively impaired, was sent to an acute care hospital without evidence of ombudsman notification, and the social worker confirmed she was unaware of the notification requirement. Additionally, a resident with severe cognitive impairment was transferred to a hospital, and again, no evidence of ombudsman notification was found. In another instance, a resident and their representative did not receive written notice of the reason for transfer/discharge, nor was the ombudsman notified. The facility's own policy indicated responsibilities for informing appropriate parties of transfers or discharges, but staff interviews and document reviews showed these procedures were not followed. The survey team discussed these deficiencies with facility leadership, but no further evidence of compliance was provided before the survey exit.
Failure to Notify Ombudsman of Resident Hospital Transfer
Penalty
Summary
The facility failed to notify the ombudsman of a resident's transfer to the hospital, as required by federal and state regulations. A resident reported having recently returned from the hospital, and a review of their progress notes confirmed a documented transfer for further evaluation of shortness of breath. During an interview, the Nursing Home Administrator acknowledged being unaware of the requirement to notify the ombudsman about such transfers. This deficiency was identified through resident interview, record review, and staff interview, and was evident for one resident reviewed for hospitalizations.
Failure to Notify Ombudsman of Resident Hospital and ED Transfers
Penalty
Summary
The facility failed to notify the State Long-Term Care Ombudsman of hospital and emergency department (ED) transfers for two residents, as required by facility policy. One resident experienced a change in condition and was transferred to the hospital, but this transfer was not included in the monthly report sent to the Ombudsman. The omission was confirmed by the staff member responsible for submitting these reports, who acknowledged that the transfer should have been reported. Another resident was transferred to the ED on two separate occasions due to changes in condition and returned to the facility the same days. These ED transfers were also not included in the monthly report to the Ombudsman. The staff member responsible for notifications indicated a lack of awareness that ED transfers required notification to the Ombudsman, resulting in these events not being reported as mandated by facility policy.
Failure to Notify Ombudsman of Facility-Initiated Transfer
Penalty
Summary
The facility failed to notify the State Long Term Care Ombudsman of a facility-initiated transfer for one resident. The resident, who had diagnoses including End Stage Renal Disease and Dependence on Renal Dialysis, was initially admitted on 08/29/2024 and re-admitted on 04/15/2025. Nurse's notes documented that the resident was transferred to the hospital on 03/30/2025 and returned to the facility on 04/15/2025. However, a review of the Emergency Transfer Log for March and April 2025 showed that this transfer was not recorded. During interviews and record reviews with the Social Service Director and the Administrator, both confirmed that the resident's transfer to the hospital was not included in the notification list sent to the State Long Term Care Ombudsman, as required. The Social Service Director acknowledged responsibility for completing and sending the Emergency Transfer Log and confirmed the omission. The Administrator also confirmed that the Ombudsman was not notified of the facility-initiated transfer, which should have occurred.
Failure to Provide Written Notification of Resident Transfer
Penalty
Summary
Facility staff failed to provide written notification of transfer to a resident and their responsible representative when the resident was hospitalized. Record review showed that the resident was transferred to the hospital, and interviews with both a Registered Nurse/Unit Supervisor and a Licensed Practical Nurse confirmed that only verbal notification was given to the resident's representative regarding the transfer and its reasoning. There was no evidence that written notification was provided as required.
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