Failure to Provide Required Transfer Documentation and Notifications
Penalty
Summary
Facility staff failed to provide written notice to a resident and their representative regarding a transfer to a local hospital for evaluation. Medical record review showed that the resident was treated for abnormal laboratory results by their primary provider, and nursing staff documented the resident's hospitalization the following day. However, there was no evidence in the medical record of documentation regarding the resident's change of condition or the transfer for treatment prior to the hospitalization. The Director of Nursing confirmed that nursing staff did not create or provide the required transfer documentation to the resident or their representative before the transfer occurred. Additionally, another resident's medical record indicated that the resident called 911 and was transported to the emergency room, but the record lacked documentation of the transfer location, reason for transfer, and required information provided to the receiving health care institution. There was also no evidence that the resident received a written discharge notice or information about the facility's bed hold and return policy. The record did not document the resident's orientation or physician notification. The Director of Nursing confirmed that the only documentation related to this hospital transfer was a nurse's note indicating the resident called 911, with no additional documentation available.