Failure to Provide Required Transfer/Discharge Notices and Ombudsman Notification
Penalty
Summary
The facility failed to provide required documentation and notifications related to resident transfers and discharges for three of five residents reviewed. Specifically, for one resident with multiple complex diagnoses including arthritis, chronic pain, acute kidney failure, and multiple myeloma, there was no evidence that a bed hold notice or a notice of transfer was given to the resident or their representative when the resident was transferred to the hospital due to low hemoglobin. Additionally, the ombudsman was not notified of this transfer. Interviews with the Administrator, DON, and Regional Director of Operations confirmed these omissions. Another resident with chronic respiratory failure, COPD, multiple sclerosis, and mental health diagnoses was discharged to the hospital for uncontrolled pain, but there was no evidence of ombudsman notification at the time of discharge. A third resident with COPD, pulmonary hypertension, and heart disease left the facility and did not return, and again, there was no evidence that the ombudsman was notified of the transfer. Review of facility policy confirmed that written notice of transfer or discharge, including the reason, bed hold policy, and ombudsman contact information, should be provided to the resident or representative and sent to the ombudsman, but this was not done in these cases.