F0628

D

Failure to Provide Required Transfer/Discharge Notice and Ombudsman Notification

City Of Industry, California Survey Completed on 02-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to complete the required transfer/discharge notification process for one sampled resident when the resident was transferred to a general acute care hospital. The resident had a history of hemiplegia, hemiparesis following cerebral infarction, and dementia, and was documented as lacking capacity to understand and make decisions, with an MDS showing severely impaired cognitive skills and need for partial/moderate assistance with most ADLs. On the day of transfer, a physician’s telephone order directed that the resident be transferred to a hospital via 911 due to altered mental status and desaturation, and progress notes documented that the resident was transferred by 911 for altered mental status, increased respirations, and desaturation.

Record review showed that there was no Notice of Transfer or Discharge (NTD) in the resident’s medical record related to this hospital transfer. In a telephone interview, the RN who received the transfer order stated that they should have completed the NTD form and faxed it to the ombudsman after the resident was transferred. The ADON, after reviewing the medical record, confirmed that no NTD form could be found and stated that the NTD is important to inform the resident and family of the transfer or discharge and to fax to the ombudsman prior to transfer or discharge. The facility’s policy titled “Transfer or Discharge, Facility-Initiated” indicated that the NTD should be given as soon as practicable but before transfer or discharge when an immediate transfer is required by urgent medical needs, that notice is to be provided to the resident, representative, and LTC ombudsman when practicable, and that nursing notes will include documentation of appropriate orientation and preparation of the resident prior to transfer or discharge.