Lack of Documented Arrangements for Patient Transfer in Emergencies
Penalty
Summary
The facility failed to develop and document arrangements with other LTC facilities and providers to receive patients in the event of limitations or cessation of operations, as required for maintaining continuity of services. During a review of the emergency preparedness plan, surveyors found no evidence of such arrangements. This deficiency was confirmed through interviews with the Maintenance Director and Administrator during the survey observation period. No specific patient medical histories or conditions were mentioned in the report, and the deficiency was identified through record review and staff interviews rather than through direct patient impact.
Plan Of Correction
Element 3 - The Environmental Services Director and the Nursing Home Administrator will be educated on the requirement to develop arrangements with other Long Term Care (LTC) facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients on or before June 10th, 2025. Element 4 - The QAPI Committee will be tasked with reviewing the updated risk assessments and emergency preparedness plan quarterly x3 to ensure ongoing relevance and effectiveness until substantial compliance has been determined by the QAPI Committee. Any identified issues will trigger retraining and/or corrective action. Element 5 - The Nursing Home Administrator is responsible for maintaining compliance.