Failure to Provide Written Notice of Transfer Prior to Hospitalization
Penalty
Summary
The facility failed to provide written notice of transfer to residents and their representatives prior to transferring them to an acute care hospital. This deficiency was identified through record review and staff interviews, which revealed that for three sampled residents who were transferred to a hospital, neither the residents nor their representatives received the required written notification. The Director of Nursing (DON) confirmed that the facility did not issue written notices of transfer for these cases and was unaware of the requirement to do so. Specific incidents included a resident transferred due to aggressive behavior, another with decreased blood oxygen saturation and level of consciousness, and a third experiencing unusual physical discomfort and difficulty standing. In each case, progress notes documented the transfer to an acute care hospital, but there was no evidence of written notice being provided. The DON described the process for transferring residents and the forms sent with them but did not include a written letter of transfer as part of the process.