Failure to Provide Written Notice of Hospital Transfer
Penalty
Summary
The facility failed to provide written notices of transfer to residents and their representatives when residents were transferred to a hospital. Record review and staff interviews revealed that three residents who were hospitalized for various acute medical conditions, including tremors and unresponsiveness, abnormal heart rate with difficulty breathing, and abnormal CO2 levels, did not receive the required written notification of transfer. The facility's policy on emergency transfer or discharge did not include the requirement to provide such written notice prior to transfer. Interviews with the ADON, interim DON, and an LPN confirmed that written notices of transfer were not given to any residents transferred to the hospital, and staff were unaware of the regulatory requirement to do so. A review of the electronic medical records for the affected residents showed no evidence of written transfer notices being provided. The ADON stated that 54 residents had been transferred to a hospital during the review period, and none had received the required written notice.