Failure to Complete Transfer/Discharge Notice and Notify Ombudsman for Hospital Transfer
Penalty
Summary
The facility failed to complete a Notice of Proposed Transfer/Discharge (NPTD) and failed to notify the long-term care Ombudsman when a resident was transferred to a general acute care hospital. The resident had been initially admitted with chronic pain syndrome and, per a history and physical dated several months prior, had the capacity to understand and make decisions. A subsequent MDS indicated the resident had intact cognition and was independent with daily activities and mobility. On the date of transfer, a physician order directed that the resident be transferred to another general acute care hospital via paramedics, and progress notes documented that the resident was transferred for pain. Interviews and record review showed that no NPTD was completed or filed in the resident’s medical record for this transfer. An LVN stated that the nurse who discharged the resident should have completed an NPTD during the transfer process. The DON confirmed that an NPTD could not be found in the resident’s record and stated that the NPTD should have been completed and maintained in the record. An RN explained that the NPTD’s purpose was to inform the resident of the transfer destination and the reason for the transfer, and that it was the facility’s practice to place the NPTD in the medical record as proof of completion. The facility’s policy on Proposed Transfer and Discharge Notice required that written notice be provided to the resident and, if known, a family member or representative, stating the reasons for the transfer or discharge as soon as practicable before it occurred.
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