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F0628
C

Failure to Provide Written Notification of Hospital Transfers

Lexington, North Carolina Survey Completed on 05-22-2025

Penalty

Fine: $23,120
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide written notification to the responsible party (RP) or resident regarding transfers to the hospital for two residents who experienced changes in condition. In multiple instances, nursing notes documented that residents were transferred to the hospital and later readmitted to the facility, but there was no evidence in the medical record of written notification being provided to the RP or the resident. The Director of Nursing (DON) confirmed that while the transfer form was sent with the resident to the hospital and the RP was notified by phone, she was unaware that written notification was also required to be mailed to the RP and given to the resident. One resident had diagnoses including respiratory failure and diabetes and was noted to be severely cognitively impaired. Another resident had a guardian for medical and financial concerns. In both cases, the RPs confirmed they were notified by phone but did not receive any written communication regarding the hospital transfers. The facility did not have a process in place to provide written notification of the reason for transfer, which was confirmed by staff interviews and review of the medical records.

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