Failure to Provide Required Written Notification and Ombudsman Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to residents and/or their representatives regarding the reason for transfer to the hospital, and also failed to notify the ombudsman of these transfers. This deficiency was identified for two residents. One resident with severe cognitive impairment and multiple diagnoses, including cerebral infarction and vascular dementia, was transferred to the hospital on several occasions due to changes in mental status, physical and verbal aggression, and symptoms suggestive of a stroke. Despite these transfers, there was no documentation in the electronic medical record of written notice being provided to the resident or their representative, nor was there evidence of ombudsman notification for the relevant period. Another resident with moderate cognitive impairment and multiple diagnoses, including encephalopathy and diabetes, was transferred to the hospital after a significant bleeding event. The medical record similarly lacked documentation of written notification to the resident or their representative regarding the reason for transfer. The facility administrator confirmed that written notifications were not provided and that the ombudsman was not notified of the hospital transfers, stating unawareness of the requirement. The facility's own policy requires written notice and ombudsman notification as soon as practicable in cases of urgent medical need, but this was not followed.