Failure to Provide Required Transfer/Discharge Notices and Ombudsman Notification
Penalty
Summary
The facility failed to provide written notice of transfer or discharge to residents and to notify the Ombudsman when residents were transferred from the facility to the hospital. Specifically, two residents who were hospitalized did not receive the required written notice of transfer/discharge, and there was no evidence that the Ombudsman was informed of these transfers. Record reviews showed that neither resident had documentation of receiving the notice, and interviews with the residents confirmed they did not recall receiving such notification. One resident was cognitively intact at the time of transfer, while the other was severely cognitively impaired. Staff interviews revealed that nursing staff sent clinical documents such as face sheets, order summaries, and medication administration records with the residents during transfer, but did not include the required notice of transfer. Social services staff, who were responsible for providing these notices, confirmed that the notices were not completed or sent for the two residents in question. Additionally, the Ombudsman was not notified of the transfers, as the process relied on having a copy of the notice, which was not available for these cases.