Failure to Provide Written Notice of Transfer to Residents or Representatives
Penalty
Summary
The facility failed to provide written notice of transfer, including the reason for transfer, to two residents or their representatives as required by regulations. For one resident with a history of COPD, diabetes mellitus type 2, heart failure, and major depressive disorder, the facility transferred the resident to the emergency department due to chronic diarrhea and abdominal pain. Although the resident opted for a bed hold, the Bed Hold/Therapeutic Leave Form did not include the reason for transfer, and no written notice of transfer was found in the resident's electronic health record or progress notes. The Director of Nursing confirmed that the required written notice was not provided. Similarly, another resident with diagnoses including hemiplegia, hemiparesis, systemic inflammatory response syndrome, and COPD was transferred to the hospital and was expected to return. The Bed Hold/Therapeutic Leave Form for this resident also lacked the reason for transfer, and no written notice of transfer was present in the electronic health record or progress notes. The Director of Nursing confirmed that the facility did not provide the resident or their representative with the required written notice of transfer.