Failure to Provide Required Written Transfer Notices with Specific Reasons
Penalty
Summary
The facility failed to provide residents and their representatives with written notices of transfer that included all required information during emergent transfers to the hospital. Specifically, for two residents who experienced acute medical events requiring hospital transfer, there was no documentation that written transfer notices were given to either the residents or their representatives at the time of transfer. In both cases, the facility's documentation only indicated that the representatives were notified by phone, and there was no evidence in the electronic medical record (EMR) that written notices were provided as required by facility policy. Additionally, the transfer notices that were completed did not specify the actual medical reasons for the transfers. Instead, the notices used a generic statement of "inability to meet resident's needs" rather than detailing the specific clinical circumstances, such as allergic skin reaction with difficulty breathing or symptoms like pallor, diaphoresis, lethargy, low blood pressure, and urinary issues. Interviews with facility staff, including the DON, confirmed the lack of documentation and the omission of specific reasons for transfer in the written notices.