F0628

C

Failure to Provide Required Written Hospital Transfer Notices to Residents and Responsible Parties

Kannapolis, North Carolina Survey Completed on 03-18-2026

Penalty

Fine: $26,685

Summary

The deficiency involves the facility’s failure to provide residents and their responsible parties (RPs) with written notices of transfer to the hospital, including the reasons for those transfers, for four residents reviewed for hospitalization. For Resident #33, who was cognitively intact per a quarterly MDS assessment, the medical record showed multiple hospital transfers for shortness of breath, nausea, vomiting, and abdominal pain between May and December 2025. Although the RP reported always being informed by phone of these hospital transfers, there was no documentation that any written notice of transfer, including the reason for each transfer, was provided to either the resident or the RP for any of these hospitalizations.

Resident #53, who had moderately impaired cognitive skills for daily decision making per a quarterly MDS assessment, was transferred to the hospital following a fall and on two additional occasions for altered mental status. The resident was readmitted after each hospitalization. The medical record contained no documentation that written notices of transfer, including the reasons for the transfers, were provided to the resident or the RP for any of these hospitalizations. Attempts to interview the RP were unsuccessful. Staff interviews revealed that the RP was notified by phone of the change and reason for the hospital transfer, but there was no identified process or responsible party for issuing the required written notice.

Resident #69, who had moderately impaired cognition per a quarterly MDS assessment, was transferred to the hospital for shortness of breath and later readmitted. The medical record lacked documentation that a written notice of transfer, including the reason for the transfer, was provided to the resident or the RP. The RP confirmed being informed by phone of the hospital transfer but reported not receiving anything in writing. Resident #31, who was cognitively intact and listed as her own RP, was transferred to the hospital with complaints of shortness of breath and low oxygen saturation and was later readmitted. The record similarly showed no documentation that a written notice of transfer, including the reason for the transfer, was provided to the resident or her emergency contact.

Across all four cases, interviews with Unit Manager #1 indicated that when residents were transferred to the hospital, clinical documents such as the face sheet, medication list, any DNR information, other pertinent information, and the bed-hold policy were sent with the resident, and the RP was notified by phone of the change and reason for transfer. However, Unit Manager #1 did not know who was responsible for providing the written notice of transfer. Social Worker #1, who had been employed for approximately three weeks at the time of the survey and was not present during many of the transfer dates, stated she was unaware that a written notice of transfer including the reason for the hospital transfer was required and therefore did not provide such notices. Former Social Worker #2, who worked at the facility for about seven months, also stated she was unaware of the requirement for written notices of transfer and had not been informed to provide this document for any of the residents’ hospital transfers. The Administrator, employed since November 2025, similarly stated she was not aware that written notification was required to be given to the resident and/or RP when a resident was transferred to the hospital.