Failure to Send Immediate Written Discharge Notice With Emergency Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to provide an immediate written notice of discharge to the receiving hospital when a resident was emergently transferred and discharged. The facility’s Emergency Transfer or Discharge policy required that, when an emergency transfer or discharge occurs, the receiving facility be notified that the transfer is being made and that a transfer form be prepared and sent with the resident. Resident #24 was admitted with traumatic brain injury with loss of consciousness and a mood disorder, was cognitively intact with a BIMS score of 14, and had documented behaviors including rejecting care and exhibiting physical and verbal behaviors. Nursing notes documented that the resident became increasingly upset, yelling and cursing at staff, hoarding medications, attempting to throw themself from the bed, attempting to hit staff, and threatening suicide if not allowed to leave. An immediate discharge written notice was completed, citing drastic violent episodes that endangered the health and safety of others and indicating that police intervention was required for removal. On the date of the incident, the LPN reported providing the immediate written discharge notice to the resident and explaining its contents, after which the resident discarded the notice. The resident was then transported to the hospital by police following threats of self-harm and continued requests to leave the facility. The administrator later stated they assumed all medical transfer forms, including the immediate discharge notice, had been sent with the resident. However, another LPN stated that only a face sheet, medical diagnosis list, and medication list were sent, and that a copy of the immediate discharge notice was not included with the transfer documentation. The hospital case manager confirmed that the hospital did not receive the immediate discharge notice at the time of transfer and only obtained it later when contacting the facility about discharging the resident back, demonstrating that the required immediate written discharge notice was not provided to the receiving hospital at the time of transfer.
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