Failure to Provide Required Transfer/Discharge Documentation and Notification
Penalty
Summary
The facility failed to properly document and notify residents and their representatives regarding transfers or discharges, as required. For one resident with severe cognitive impairment and multiple mental health diagnoses, there was no documentation in the medical record of notifications to the resident or their representative when the resident was transferred to the hospital. The required Nursing Home Transfer and Discharge Notice (AHCA Form 3120-0002) was not found in the resident's records, nor was there evidence that the notice was given or mailed to the resident or their representative. Interviews with facility staff confirmed that the notice was not provided to residents or their representatives, but only faxed to the Ombudsman monthly. Another resident, with a history of cardiac and vascular conditions, was discharged home, but the discharge summary and instructions were incomplete and unsigned. The discharge documentation lacked essential information such as the primary physician, contact information for home health and medical equipment providers, and details on appointments, medication reconciliation, and disease management. There was also no evidence that the required transfer and discharge notice was present in the resident's records or that any information was provided to the resident upon discharge, as confirmed by the DON after reviewing the records.