Failure to Provide Written Transfer Notices and LTCO Notification for Hospital Transfers
Penalty
Summary
Surveyors identified that the facility failed to provide required written notifications of transfer for three residents who experienced facility-initiated transfers to the hospital, and also failed to notify the State Long Term Care Ombudsman (LTCO) of these transfers/discharges. The census was 61 residents, with a sample of 15, including three residents reviewed for hospitalization. One resident was admitted to the facility, transferred to the hospital, and later readmitted, while two other residents were admitted, transferred to the hospital, and did not return. When surveyors requested documentation, the facility was unable to provide written notifications of transfer for any of these hospital transfers. Review of LTCO notification emails for discharges over a one-year period showed that these hospital transfers were not included. During observations and interviews, one of the residents was seen sitting in a wheelchair at a dining room table eating breakfast. A consultant stated that the facility did not do written notifications of transfers. A licensed nurse reported that when a resident transferred to the hospital, she notified the resident’s representative by phone but did not complete a written notification of transfer. The social services staff member stated that she called families about bed holds and documented a progress note but did not complete written notifications of transfer and did not know what they were. She also stated she completed ombudsman reports on discharges, including hospital transfers, but that residents were only included if they were discharged after hospital admission, and she usually reviewed the list to ensure hospital transfers were included. The facility’s Admission, Transfer, and Discharge Policy required a 30-day advanced written notice, except in emergencies, including the reason for transfer/discharge, effective date, receiving location, LTCO contact, State Agency contact, and appeal rights, but the policy did not address written notification of hospital transfers or LTCO notification of transfers.
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