Failure to Provide Written Notification of Transfer/Discharge Appeal Rights During Hospital Transfers
Penalty
Summary
The facility failed to provide written notification of transfer/discharge appeal rights to a resident's representative during three separate hospital transfers. The resident in question had multiple complex medical diagnoses, including cerebral palsy, a left lower leg fracture, failure to thrive, Cauda Equina syndrome, severe intellectual disabilities, osteoarthritis, congenital foot deformities, and diabetes. On three occasions, the resident was transferred to the hospital for evaluation and treatment following incidents such as a left hip fracture, bruising and swelling of the left hand, wrist, and shoulder, and shortness of breath unresponsive to treatment. In each instance, while the resident's representative was notified of the transfer and the facility's bed hold policy was discussed, there was no documentation that written notification of the resident's transfer/discharge appeal rights was provided. Interviews with facility staff, including the Social Services Director, LPNs, the DON, and the Regional Nurse Consultant, confirmed that the appeal rights information was not discussed or provided in writing to the resident's representative during these transfers. The facility's policy required preparation of a transfer form and documentation of notifications, but did not specify the requirement to provide written appeal rights notification. The clinical record and staff interviews consistently lacked evidence of compliance with this regulatory requirement.