Deficient Documentation and Notification During Transfers and Discharges
Penalty
Summary
The facility failed to ensure proper documentation and notification regarding acute transfers and discharge procedures for two residents. For one resident who experienced unplanned transfers to an acute hospital, the Notice of Transfer to Acute Care Facility (NTACF) forms did not include required information about the resident representative (RR), such as contact details and confirmation of notification. Additionally, there was no documentation that the RR was informed about the facility's bed-hold policy or reserve payment, as required by both facility policy and state regulations. The Director of Nursing (DON) and Director of Admissions (DA) confirmed that these omissions occurred, and the forms were not fully completed, including missing the billing rate information. For another resident who was discharged, the discharge summary lacked the signature of the resident or RR, and there was no evidence that the discharge summary or instructions were communicated to them. The discharge summary also contained outdated vital signs, with the last recorded measurements taken several hours before the actual discharge time. Furthermore, there was no documented physician order for the discharge, and the facility's policy requiring assessment and documentation of the resident's condition at discharge was not followed. These deficiencies were identified through interviews and record reviews conducted by surveyors, who found that the facility did not adhere to its own policies or regulatory requirements regarding notification, documentation, and communication with residents and their representatives during transfers and discharges.