Failure to Provide Required Transfer Notifications and Ombudsman Notices
Penalty
Summary
The facility failed to provide required written documentation and notifications regarding resident transfers to outside facilities. Specifically, for one resident who was transferred for geriatric psychiatric care, there was no written notice sent to the resident or their representative. Additionally, for two other residents who were transferred to the hospital, there was no record of written transfer information being sent to their family representatives. Review of the facility's policy indicated that such notifications should be sent following any emergency discharge or planned transfer, but this was not done in these cases. Furthermore, the facility did not send copies of the transfer notices to the Office of the State Long-Term Care Ombudsman for any of the three residents involved. The transfer forms had a designated section for documenting that a copy was sent to the Ombudsman, but this section was left blank for all three cases. Interviews with the Ombudsman and the DON confirmed that the required notifications were not sent, and the process for doing so was not being followed at the time of the incidents.