Failure to Provide Written Notification of Transfer/Discharge
Penalty
Summary
Facility staff failed to provide written notification of the reason for transfer or discharge to a resident and the resident's representative prior to a hospital transfer. The deficiency was identified through staff interviews, clinical record review, and facility document review, which revealed that no evidence of written notification was present for the transfer that occurred on 4/3/25. When requested by the surveyor, administrative staff confirmed that they could not locate documentation showing that the required notification had been given. The resident involved had multiple diagnoses, including osteoarthritis, Alzheimer's disease, hypertension, type 2 diabetes mellitus, atrial fibrillation, chronic kidney disease stage 3, and a history of digestive system surgery. The most recent assessment indicated severe cognitive impairment, with a BIMS score of 6 out of 15. Despite these factors, there was no documentation that the resident or their representative received written notification regarding the transfer, as required.