Failure to Provide Written Notification for Resident Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to residents and their representatives regarding the reason for hospital transfers, as well as information about appeal rights and bed-hold policies, for five sampled residents. According to the facility's own policy, staff are required to obtain physician orders stating the reason for emergency transfers, ensure transfer forms and advance directives accompany the resident, and provide written notice of transfer and the facility's bed-hold policy to both the resident and their representative. However, record reviews and staff interviews confirmed that these steps were not completed for the sampled residents. For each of the five residents, documentation in the medical records, including progress notes, practitioner orders, and care plans, did not include the reason for transfer or evidence that a written notification was provided. This included residents with varying cognitive statuses, such as those with severe impairment and those who were cognitively intact. In several cases, the residents were transferred to the hospital for acute medical issues, but there was no indication that the required written notifications were completed or given to the residents or their representatives at the time of transfer. Interviews with the Regional Nurse Consultant confirmed the absence of transfer forms and written notifications for each incident. The lack of documentation and notification was consistent across all five cases reviewed, regardless of the residents' cognitive abilities or the circumstances of their transfers. The findings indicate a systemic failure to comply with both facility policy and regulatory requirements regarding resident notification during transfers to acute care settings.