Failure to Provide Written Notification of Hospital Transfer
Penalty
Summary
The facility failed to provide written notification of transfer to the hospital for three residents, as required by policy and regulation. Record review showed that for each of these residents, there was no evidence in the electronic medical record (EMR) that a written notice of transfer was given or sent to the resident or their representative. Specifically, one resident was discharged to the hospital on two occasions, another was hospitalized multiple times, and a third was transferred to an acute hospital due to lethargy and being difficult to arouse. In each case, there was no documentation of a written notification of transfer in the EMR. Interviews with facility staff, including the DON, Social Services Coordinator, and Administrator, confirmed that the facility's practice was to call the family and note it in the chart, but not to send written notifications to the resident or their representative. One resident also denied ever receiving a written notice of transfer or discharge. The facility's policy requires informing residents, family members, or legal representatives verbally and in writing of the reasons for transfer or discharge, but this was not followed for the residents reviewed.