Failure to Provide Required Written Notice of Hospital Transfer
Penalty
Summary
The facility failed to provide a resident with a written notice of transfer when the resident was sent to the hospital for evaluation and treatment. The facility’s transfer and discharge policy dated 05/2017 required that a resident be provided a written notice of transfer when practicable before transfer, even when urgent medical needs required immediate transfer. Record review showed that a quarterly MDS assessment for Resident #5 dated 06/18/25 documented an intact cognition with a BIMS score of 15. A progress note dated 09/12/25 at 3:35 p.m. stated that Resident #5 was sent to a hospital for evaluation and treatment related to seizure-like activity, high blood pressure, and elevated pulse, and that a family member was notified of the transfer. In an interview on 09/24/25, Resident #5 confirmed having been transferred to a hospital, and in a separate interview the same day, the DON described the paperwork sent with residents during transfers but did not include a written notice of transfer. The DON acknowledged that staff did not provide Resident #5 with a written notice of transfer on 09/12/25 and stated they were unaware of the requirement to provide such written notice.
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