Failure to Provide Written Transfer Notices and Discharge Summaries
Penalty
Summary
The facility failed to provide written notification to residents or their responsible representatives regarding the reason for hospital transfers for multiple residents. In several documented cases, residents were transferred to the hospital for changes in condition such as stroke, feeding tube complications, vomiting, respiratory distress, and altered mental status. Although staff reported that a copy of the face sheet, medication administration record, DNR information, change in condition form, transfer form, and bed hold policy were sent with the resident to the hospital, there was no evidence in the medical records that written notices of transfer were provided to the residents or their responsible parties. Interviews with responsible parties confirmed that they were notified by phone but did not receive any written documentation regarding the transfers. Additionally, the facility did not provide a discharge summary or a recapitulation of the resident's stay to a resident who was discharged home. The responsible party for this resident reported not receiving a discharge summary, and staff interviews revealed a lack of clarity regarding who was responsible for completing this documentation. The social worker and DON were unaware of the requirement to complete and provide a discharge summary upon discharge. Staff interviews, including those with the unit manager, DON, administrator, and social worker, consistently indicated a lack of awareness of the regulatory requirement to provide written notices of transfer and discharge summaries to residents and their responsible parties. The documentation reviewed did not include any written notifications or summaries, and staff confirmed that their practice was to notify by phone only and send documentation with the resident to the hospital, but not to the responsible party.