Failure to Notify Health Care Agent of Resident Transfer
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's Health Care Agent (HCA) was properly notified of the resident's transfer to another Skilled Nursing Facility (SNF). The resident, who had an activated Health Care Proxy due to significantly impaired cognition and a primary language of Haitian Creole, was transferred without the HCA being informed of the actual date or time of transfer. Although the HCA had requested the transfer, she was not notified when the transfer was scheduled or completed, and only learned of the transfer after being contacted by the accepting SNF. The facility's policy required prompt notification of the resident's representative regarding changes in condition or status, including discharge or transfer. Records and interviews revealed that while the social worker sent referral emails and left a voicemail for the HCA, there was no confirmation that the HCA received or acknowledged the transfer details. The Director of Social Services assumed the HCA was aware due to previous communications but did not confirm receipt or understanding. The Nurse Supervisor and Director of Nursing also did not directly communicate the transfer details to the HCA, relying on the assumption that the social services department had done so. The accepting SNF reported that they were not provided with a confirmed transfer date, time, or a completed nurse-to-nurse clinical report.