Failure to Provide Required Written Notification for Resident Transfer
Penalty
Summary
The facility failed to provide written notification of transfer to a resident and/or her representative, as well as to the Office of the Long Term Care Ombudsman (LTCO), following the resident's transfer to the emergency room for evaluation of chest pain and shortness of breath. The resident, who had diagnoses including congestive heart failure, paroxysmal atrial fibrillation, atrioventricular block, and a cardiac pacemaker, was documented as having intact memory and was at risk for complications related to her cardiac conditions. The electronic health record and facility documentation did not contain evidence that written notification was given to the resident or her representative regarding the transfer, nor was there evidence of notification to the LTCO. Interviews with administrative staff confirmed that the facility's practice was to provide verbal notification and send transfer packets with the resident, but written notifications were not provided or documented. Staff also stated that the LTCO was not notified for short-term transfers and that there was no facility policy related to written notification of resident transfers or discharges to residents and the LTCO. The lack of written notification and failure to notify the LTCO constituted a deficiency in meeting regulatory requirements for resident rights during transfers.