Failure to Provide Required Written Notifications for Transfers and Discharges
Penalty
Summary
The facility failed to provide written notification to residents and/or their representatives regarding the reasons for transfer to the hospital, and did not notify the ombudsman as required by policy and regulation. Specifically, for three residents reviewed, there was no documented evidence that written notifications were given to the residents or their legal guardians when the residents were transferred to the hospital or discharged home. For one resident with moderate cognitive impairment and a history of stroke, there was no written notification to the resident or legal guardian, nor was the ombudsman notified when the resident was transferred to the hospital for chest pain. Another resident, who was cognitively intact, was sent to the emergency room for evaluation of tremors, weakness, and stiff neck, but again, there was no documentation of written notification to the resident or representative, or notification to the ombudsman. Additionally, a third resident, also cognitively intact, was discharged home with his wife, but there was no evidence that the ombudsman was notified of the discharge as required. These findings were confirmed by the Assistant Director of Nursing, who acknowledged the lack of documentation and notifications for the residents involved. The facility's policy required written notification to both the resident/representative and the ombudsman upon transfer or discharge, but this was not followed in these cases.