Failure to Provide Required Transfer/Discharge Documentation and Notification
Penalty
Summary
The facility failed to ensure that required documentation and notifications were completed for residents who were transferred or discharged. Specifically, for three residents reviewed, there was no evidence in the medical records of proper documentation regarding the reasons for transfer or discharge, nor were there written notifications provided to the residents or their representatives as required by facility policy and federal/state regulations. The facility policy mandates that in cases of transfer or discharge, especially those initiated by the facility, documentation must be present in the resident's medical record, and written notice must be given to the resident and their representative, including information about appeal rights and bed-hold policies. For one resident, there were no progress notes indicating the reason for transfer or the resident's destination after discharge. The DON and Administrator were unable to provide documentation such as bed-hold or transfer/discharge notices, and there was confusion regarding the resident's readiness to return and the facility's bed availability. Another resident was sent to the hospital for chest pain and subsequently discharged, but the chart lacked further documentation about the resident's status or the facility's decision-making process. Dialogue between the hospital and facility indicated the facility declined to accept the resident back, citing care needs and safety concerns, but no formal notice of discharge was issued. A third resident was sent to the hospital due to a medical issue, but again, there was no documentation in the chart regarding the outcome or any bed-hold notice. Staff interviews confirmed that required documentation, including bed-hold notifications, was not found for any of the three residents. The lack of documentation and notification represents a failure to follow established procedures for resident transfers and discharges.