Failure to Provide Written Transfer Notifications for Hospitalized Residents
Penalty
Summary
Surveyors found that the facility failed to provide required written notification of transfers for three residents who were sent to the hospital. One resident experienced vomiting of a reddish-brown substance and reported right shoulder pain; the nurse obtained provider orders to send the resident to the ER via EMS, but the electronic medical record contained no evidence that written notification of the transfer was provided to the resident or representative. A second resident was sent to the ER for evaluation and treatment based on a verbal provider order documented in the progress notes, yet the electronic medical record similarly lacked documentation that written notification of the transfer was given to the resident or representative. A third resident was documented as hallucinating and talking to people who were not present, and the resident’s daughter requested that the resident be taken to the hospital; the resident was transferred, but the electronic medical record again lacked evidence of written notification of the transfer to the resident or representative. During interviews, social services staff stated that a bed-hold notice was sent with residents upon transfer and that families were notified by phone, but acknowledged they were not aware that written notification of transfers to the hospital was required. Administrative staff also stated they had not heard of the written notification requirement for hospital transfers and inquired about the applicable regulation. The facility’s transfer or discharge policy indicated that facility-initiated discharges require resident or representative notification, orientation, and documentation.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.