Failure to Provide Required Transfer/Discharge Notifications and Documentation
Penalty
Summary
The facility failed to follow its own protocols and federal requirements for providing written notification of transfer or discharge for multiple residents who were hospitalized or discharged. Specifically, the facility did not consistently complete or provide the Notice of Proposed Transfer and Discharge forms to residents, their responsible parties, or the Ombudsman as required. In several cases, there was no documentation in the medical records to show that these notifications were completed or sent, and fax confirmations to the Ombudsman were missing. This was confirmed through interviews with staff, including the Medical Records Director (MRD) and nursing staff, who acknowledged the absence of required documentation and forms in the residents' records. For example, one resident who was discharged to the community did not receive a discharge summary or a recapitulation of their stay, including important information such as home health services, follow-up appointments, and medication instructions. Other residents who were transferred to acute care hospitals on multiple occasions did not have completed Notice of Proposed Transfer and Discharge forms in their records, and there was no evidence that the Ombudsman was notified as required by facility policy. Staff interviews confirmed that the process of completing and documenting these notifications was not followed consistently. The facility's policies require that before a resident's transfer or discharge, written notification must be provided to the resident, their responsible party, and the Ombudsman, with documentation placed in the medical record. Despite these clear policies, the survey found repeated failures to provide and document these notifications for several residents, both in open and closed records. These deficiencies were acknowledged by facility leadership during interviews.