Failure to Provide Written Notification of Hospital Transfer
Penalty
Summary
The facility failed to provide required written notification of transfer to two residents and their representatives when the residents were transferred to the hospital. In both cases, the residents were hospitalized for acute medical needs, and although bed-hold notifications were given and representatives were notified by phone, there was no written notice provided that included the location and reason for transfer, as required. Documentation in the residents' electronic medical records confirmed the transfers and subsequent returns to the facility, but lacked evidence of the mandated written notifications. Staff interviews confirmed that the facility's practice was to notify representatives by phone and document the transfer in progress notes, but not to provide written notification at the time of transfer. Facility policies required written notice for transfers or discharges, including specific information such as the reason for transfer, effective date, location, appeal rights, and ombudsman contact information. However, these procedures were not followed during the unplanned hospital transfers for the two residents reviewed.