Failure to Provide Written Transfer Notification to Residents and Representatives
Penalty
Summary
The facility failed to provide written notification to residents and their representatives regarding transfers to the hospital, including the reasons for the transfers, for three residents reviewed for discharge or transfer. Clinical records for each resident contained transfer forms and discharge notices indicating the date and destination of the transfer, but there was no documentation that written notification was given to the residents or their representatives. Instead, staff reported that all transfer documents were provided to EMS, and only verbal explanations were given to the residents about the reason for transfer and the destination. Interviews with multiple LPNs and the Director of Nursing confirmed that the practice was to verbally inform residents of the transfer and provide all paperwork to EMS, rather than directly to the residents or their representatives. Staff also indicated that they did not provide written documentation to residents at the time of transfer, citing concerns that the paperwork might get lost. The facility's policy stated that transfers or discharges should be safe, orderly, and appropriate to meet the needs of the resident, but did not specify the process for written notification to residents or their representatives.