Failure to Provide Written Notification of Hospital Transfer
Penalty
Summary
The facility failed to provide written notification to residents and their Resident Representatives regarding the reason for transfer or discharge to the hospital. This deficiency was identified through record reviews and staff interviews, affecting five residents who were hospitalized for various acute medical conditions, including critical low hemoglobin, gastrointestinal bleeding, need for a tunneled catheter, increased shortness of breath, and vomiting blood. In each case, the medical records lacked documentation of written notification of transfer for either the resident or their Responsible Party on the date of hospitalization. Interviews with facility staff revealed that the Social Worker had not been sending written notifications of transfer or discharge, instead relying on verbal communication via phone calls to inform Resident Representatives. Documentation of these conversations was inconsistently recorded, sometimes only in a personal notebook or in the resident chart. The Administrator confirmed awareness of the verbal notification process but expected that written notifications would also be provided, which was not occurring at the time of the deficiency.