Failure to Provide Required Written Transfer/Discharge Notices and LTCO Notifications
Penalty
Summary
The facility failed to provide required written notifications and Long Term Care Ombudsman (LTCO) notifications to residents and/or their representatives at the time of transfer or discharge for six out of seven residents reviewed. Specifically, there was no documentation in the clinical records of written transfer notices describing the reason for transfer for multiple hospitalizations involving residents with significant medical conditions such as stroke, kidney failure, high blood sugars, abdominal pain, and terminal illness. The facility's policy required that written notice be given to the resident or their representative and a copy sent to the State LTCO office prior to transfer or as soon as practicable, but this was not followed in these cases. Interviews with facility staff revealed a lack of awareness and responsibility regarding the requirement to provide written notifications. Staff members reported notifying families by phone and sending an "e-interact" form with residents to the hospital, but were unaware of the need for written notifications. Social services staff also confirmed that the LTCO was not notified of the transfers as required. Additionally, staff interviews indicated that there was no clear assignment of responsibility for providing these written notices during transfers or hospitalizations. For two residents, the facility also failed to communicate a report to the receiving hospital regarding the resident's condition at the time of transfer. Review of transfer forms showed that the necessary information was not provided to the receiving hospitals, and staff confirmed that reports were not called in for these transfers. These failures were observed through record reviews and staff interviews, confirming that the required notifications and communications were not completed as per facility policy and regulatory requirements.