Failure to Notify Resident and Representative of Hospital Transfer
Penalty
Summary
The facility failed to ensure that a resident and their representative were notified in writing of the reason for a transfer to the hospital. Specifically, a resident with severe cognitive impairment was transferred to the hospital due to shortness of breath and wheezing, but there was no documented evidence that the resident's family or representative received written notification of the transfer. Additionally, the facility did not provide the required notification to the State Long-Term Care Ombudsman's Office. Interviews with facility staff, including the Director of Social Services and the Director of Nursing, revealed that the responsibility for providing the transfer/discharge notice fell on the social workers and nursing staff. However, they failed to complete this task for the resident in question. The facility Administrator acknowledged that the resident's family should have received written information regarding the transfer and discharge process, but this did not occur. The Ombudsman office confirmed that they did not receive any documentation regarding the resident's discharge.
Plan Of Correction
Plan of Correction: Approved March 13, 2025 Immediate action(s) taken for the resident(s) found to have been affected include: ò No immediate action could be taken for residents found to be affected. Identification of other residents having the potential to be affected was accomplished by: ò Residents who are transferred and/or discharged from the facility, planned or unplanned have the potential to be affected. Action taken/systemic change put into place to reduce the risk of future occurrence include: ò Director of Social Services or designee will identify and implement a compliant Transfer and Discharge Form by 3/20/25. ò Director of Social Services or designee will establish a transfer and discharge communication protocol with the local ombudsman by 3/31/25. ò Administrator or designee will in-service Social Services Staff on Transfer and Discharge Protocol by 3/31/25. ò Director of Nursing or designee will in-service Licensed Nursing Staff on Transfer and Discharge Protocol by 3/31/25. How the corrective action will be monitored to ensure the deficient practice will not reoccur: ò Director of Social Services or designee will audit 100% of resident discharges and/or transfers for written notification of reason for transfer and/or discharge to resident or resident representative and the ombudsman. Beginning on 4/1/25 audits will be weekly x4 weeks and then Monthly x 3 months with a goal of 100% compliance. Findings will be reported during QAPI. Date of Completion and Person Responsible: 4/20/25, Director of Social Services