Failure to Provide Required Transfer and Discharge Documentation
Penalty
Summary
The facility failed to provide the required transfer and discharge documentation for a resident who was transferred to a General Acute Care Hospital (GACH). Specifically, the resident was not given a Notice of Transfer or Discharge, was not provided with a notice of a bed hold, and the Ombudsman was not notified of the transfer or discharge. These omissions were confirmed through interviews and record reviews with the Medical Records Director, a Licensed Nurse, and the Director of Nursing, all of whom acknowledged that the necessary documents were missing from the resident's medical record and had not been completed as required by facility policy. The resident involved had a history of acute and chronic respiratory failure with hypoxia and diabetes, and was able to make his own health care decisions. On the date of transfer, the resident experienced a significant decline in oxygen levels and other symptoms, leading to a physician's order for transfer to the emergency room. Despite this change in condition and subsequent transfer, the facility did not complete or provide the required documentation or notifications related to the resident's rights, appeal process, or bed-hold policy.