Failure to Document Required Information on Transfer/Discharge Notices
Penalty
Summary
The facility failed to properly document and communicate required information on the Notice of Transfer/Discharge (NTD) forms for three residents. For one resident with depression, anxiety disorder, gait abnormalities, and schizophrenia, the NTD form incorrectly stated the reason for transfer as health improvement, despite the resident being transferred to another skilled nursing facility (SNF) of the same care level, contrary to the resident's discharge goal of moving to a lower-level care facility. The responsible staff did not provide the NTD form to the resident prior to discharge, and interviews confirmed that the discharge plan was not accurately reflected in the documentation. Another resident, diagnosed with COPD, diabetes mellitus, and schizophrenia, was transferred to a different SNF without any reason documented on the NTD form. The resident was cognitively intact and self-responsible, but both the Assistant Director of Nursing (ADON) and Director of Nursing (DON) acknowledged that the required reason for transfer was missing from the documentation. This omission was confirmed during interviews and record reviews. A third resident, with hypertension, chronic kidney disease, dementia, and schizophrenia, was transferred to an Independent Living Home (ILH), but the NTD form did not specify the location of the ILH. This resident was severely cognitively impaired and required significant assistance with daily activities. Facility policy requires that the reason for transfer/discharge and the location be clearly documented and communicated to the resident and/or their representative, but this was not done in these cases.