Failure to Provide Required Written Transfer and Discharge Notifications
Penalty
Summary
The facility failed to provide and document adequate preparation and orientation for resident representatives to ensure safe and orderly transfers or discharges. Specifically, the facility did not send written transfer or discharge notifications to residents, their representatives, or the local ombudsman in a language and manner they could understand. Interviews with the administrator and the ombudsman confirmed that these notifications were not being sent, and the administrator was unaware of the reason for this lapse. The facility's own policy required such notifications and documentation, but these steps were not followed. A review of the facility's discharge report over a three-month period showed 55 discharges to various settings, including acute care hospitals, funeral homes, hospice, other nursing homes, and private homes, both with and without home health services. The facility's policy also required that the reasons for transfer or discharge be recorded in the resident's medical record, but the report indicates that the required written notifications were not provided as stipulated.