Failure to Provide Required Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide written notice of transfer or discharge to a resident and/or their representative, as well as to the Office of the State Long Term Care Ombudsman, as required by both facility policy and regulation. Review of the electronic health record for the resident who was discharged showed no documentation that such notice was given. Multiple staff interviews confirmed a lack of awareness or implementation of the process for providing and documenting these notifications. The Social Services Director, who was new to the role, was unsure if the notice had been provided and could not locate any related documentation. The Charge Nurse stated that providing such notice was a new policy and that nothing had been sent to the ombudsman. The Regional Nurse Consultant and the Administrator both acknowledged that the required notifications were not present in the resident's record and confirmed that notification to the ombudsman is a regulatory requirement. The facility's policy, revised in March 2021, specifies that residents and/or their representatives must be notified in writing, in a language and format they understand, of the specific reason for transfer or discharge, the date, the location, and their rights to appeal. It also requires that a copy of the notice be sent to the Office of the State Long-Term Care Ombudsman. Despite these requirements, there was no evidence that the resident or their representative received the required written notice, nor that the ombudsman was notified, at the time of the resident's discharge.