Failure to Provide Required Transfer Notices
Penalty
Summary
Fulton County Medical Center was found to be non-compliant with specific requirements of 42 CFR Part 483, Subpart B, concerning notice requirements before transfer or discharge of residents. The facility failed to provide written notice to the State Long-Term Care Ombudsman and the residents or their responsible parties regarding emergency transfers to the hospital for two residents. This deficiency was identified during a Medicare/Medicaid Recertification survey, State Licensure survey, and a Civil Rights Compliance survey. The first case involved a resident who was cognitively intact and had his sister listed as the emergency contact. On two separate occasions, the resident was transferred to the hospital due to medical emergencies, including a severe skin rash and episodes of hematuria and rectal bleeding. However, there was no documented evidence that the required written notices were provided to the Ombudsman or the resident's sister regarding these transfers. The second case involved another cognitively intact resident who was transferred to the hospital after being found with abnormal vital signs and lab results indicating a potential infection. Similar to the first case, there was no documented evidence that the required written notices were provided to the Ombudsman or the resident's responsible party. The Director of Nursing confirmed the lack of documentation for both residents' transfers.
Plan Of Correction
1. Facility provided transfer and discharge notification report to the State Ombudsman office for the month of March on 4/19/2025. 2. Facility created a formal notification letter on 4/20/2025. Letter that will be updated, specific to each transfer and discharge and be provided to the resident/resident representative starting 4/21/2025. 3. On the spot education began on 4/21/25 for the Interdisciplinary Team and Registered Nurses which reviews Notice requirements 483.15(c)(3)-(6)(8) and new process of notification letter and reporting to ombudsmen. Education will be completed by 5/21/25. 4. Administrator or designee will complete monthly audits of written notification to resident/resident representative and ombudsman reporting. Audits will be completed over 3 consecutive months and findings will be reported at the Quality Assurance and Performance Improvement meeting.