Failure to Provide Written Transfer/Discharge Notification to Residents, Representatives, and Ombudsman
Penalty
Summary
Facility staff failed to provide written notification of the reasons for transfer and/or discharge to residents and their representatives in four cases out of fifty-five sampled. In each instance, the clinical record review and staff interviews revealed that no evidence could be found that written notice was given to either the resident or their representative at the time of transfer to the hospital. The residents involved had significant medical histories, including conditions such as cerebral infarction, diabetes, chronic kidney disease, dementia, mood disorders, hemiplegia, hypertension, seizures, and respiratory failure. Cognitive assessments indicated that some residents were severely impaired, while others were cognitively intact. For one resident, the facility also failed to provide evidence that the local long-term care ombudsman was notified of the transfer or discharge, as required. Staff interviews confirmed that no documentation or notification was sent to the ombudsman, the resident, or the family in this case, due to a lack of awareness that the resident had been transferred. Facility policy required that transfer notices be provided as soon as practicable to both the resident and their representative, but this was not followed in the cited cases. The surveyors requested documentation and reviewed facility policies, but no further information or evidence of compliance was provided prior to the survey exit. The deficiency was discussed with facility leadership during end-of-day meetings, and the lack of written notification was confirmed by staff, including the DON, ADON, and social worker, who stated that discharge notifications were not completed.