Failure to Provide Required Transfer Notices and Ombudsman Notifications
Penalty
Summary
The deficiency involves the facility’s failure to follow required transfer and discharge procedures, including providing written notices to residents and notifying the LTC Ombudsman. Facility policies titled "Transfer and Discharge" and "Bed Hold Notice Upon Transfer" required that, for non-emergency transfers or discharges initiated by the facility, written transfer/discharge notices be provided to the resident or representative and to the Ombudsman, and that for emergency transfers, a notice of transfer and the facility’s bed-hold policy be provided to the resident and representative, with copies of emergency transfer notices sent to the Ombudsman. The bed-hold policy further required that, at the time of transfer for hospitalization or therapeutic leave, the resident and/or representative receive written notice specifying the duration of the bed-hold policy and information about return to the next available bed, or within 24 hours in the case of an emergency transfer. For one resident, surveyors found that the written Notice of Transfer/Discharge dated 11/17/25 showed both the white and yellow carbon copies remained in the closed medical record, indicating the yellow copy had not been given to the resident at the time of transfer to an acute care facility. RN 1 and the DON both stated that the process for a transfer included completing the Notice of Transfer/Discharge form and providing the yellow copy to the resident, and the DON confirmed that the notice in this case had not been provided to the resident. Review of the same resident’s Bed Hold Notification dated 9/18/25 showed blank entries for the Confirmation of Transfer and Bed Hold Provision and the 24-Hour Confirmation section, and the DON verified these sections should have been completed but were left blank. Surveyors also identified that the facility failed to document notification of the LTC Ombudsman for three residents who were transferred or discharged. For the first resident, the Notice of Transfer/Discharge dated 11/17/25 did not show that the Ombudsman was notified. For a second resident, admitted and later discharged from the facility, the Notice of Transfer/Discharge dated 10/23/25 similarly lacked documentation of Ombudsman notification. For a third resident transferred to an acute care facility, the Notice of Transfer/Discharge dated 1/22/26 also failed to show Ombudsman notification. The SSD stated that nurses are responsible for notifying the Ombudsman when a resident is transferred to acute care, and that she notifies the Ombudsman when residents are transferred to another facility or home, retaining fax confirmation sheets and attaching them to the notice; however, the Notices of Transfer/Discharge for all three residents had blank entries in the section "copy to LTC Ombudsman Office-date." The SSD and DON both acknowledged that these sections should have been completed and that, without documentation, it could not be verified that the Ombudsman had been notified.
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