Failure to Provide Required Written Transfer Notices for Hospital Transfers
Penalty
Summary
The facility failed to provide a written transfer notice containing all required information to two out of five residents, or their representatives, who were reviewed for hospital transfers. For one resident with intellectual disabilities and a BIMS score indicating cognitive intactness, there was no evidence in the electronic medical record (EMR) that a written notice of transfer was given after a facility-initiated hospital transfer. Similarly, for another resident with major depressive disorder and moderate cognitive impairment, the EMR did not show that a written notice of transfer was provided after two separate facility-initiated hospital transfers. Record reviews of the residents' admission records, quarterly Minimum Data Set (MDS) assessments, and various EMR tabs (Evaluations, Documents, Progress Notes) failed to reveal documentation of the required transfer notices. During an interview, the Administrator confirmed that the facility had not been sending out transfer notices when residents were discharged and stated unawareness of this requirement.