Failure to Provide Written Notification of Hospital Transfers
Penalty
Summary
The facility failed to provide written notification of hospital transfers to residents and/or their representatives for three residents reviewed. According to the facility's policy, written notice of transfer or discharge should be documented in the medical record and provided to the resident or their legal representative. However, for all three residents, there was no evidence in the electronic medical record (EMR) that such written notification was given. Instead, transfer forms were sent with emergency or transportation personnel to the receiving hospital, but not to the residents or their representatives. Staff interviews confirmed that while phone calls were made to notify families, no written notices were provided. The residents involved had significant medical histories, including diagnoses such as metabolic encephalopathy, Alzheimer's disease, repeated falls, resistance to multiple antimycobacterial drugs, dehydration, atrial fibrillation, dementia, depression, anxiety disorder, hypertension, heart failure, and chronic obstructive pulmonary disease. One resident was transferred after a witnessed fall with head and hip injury, while another was transferred multiple times for altered mental status, fever, and chest pain. Despite these events, there was no documentation of written notification of the transfers to the residents or their representatives, as required by facility policy.