Failure to Provide Required Discharge and Transfer Notifications
Penalty
Summary
The facility failed to provide required discharge and transfer notifications to residents, their representatives, and the Ombudsman for two residents. In the first case, a resident with diagnoses including diabetes type two, paraplegia, chronic obstructive pulmonary disease, pain, and schizoid personality disorder was admitted to the facility and later transferred to the hospital following a change in condition and declining vital signs. Documentation showed the resident was transferred via emergency squad, but there was no evidence of a transfer summary or notification sent to the hospital, the resident, the resident's representative, or the Ombudsman during the relevant period. In the second case, another resident with a history of complications post femur fracture surgery, depression, and myeloma was admitted and subsequently discharged to the hospital after a syncopal episode and possible urinary tract infection. The transfer occurred after the resident was seen by an outside physician. Review of the medical records revealed no documentation of discharge or transfer notification to the resident, the resident's representative, or the Ombudsman. Interviews with facility staff, including a Managed Care Provider and the Administrator, confirmed that the required notifications and summaries were not completed or documented for either resident. The findings indicate that the facility did not meet regulatory requirements for communication and documentation during resident transfers and discharges.
Plan Of Correction
Tag: F 0628 Facility has provided resident #28 and #42 with transfer notices, as well as updated transfer log and sent to ombudsman. Administrator reviewed all transfer/discharges from 5/1/25 through 5/30/25 for corresponding notice of transfer/discharge. Administrator or designee will review discharged patients for the last 30 days to ensure they received a transfer/discharge notice. If they did not receive a notice, they will be issued one, this will occur on or before 6/25/25. Administrator provided education to social service designee on transfer/discharge notice requirements on 6/17/25. Administrator or designee will audit 3 discharge residents weekly x4 weeks to ensure proper notice of transfer/discharge. Results of audits will be reviewed by the QAPI committee for further recommendations.