Failure to Provide Required Written Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide required written notices of transfer or discharge to residents or their representatives prior to transfer, as evidenced by record review and staff interviews. The facility’s Transfer or Discharge policy dated April 2025 did not include the requirement to notify the resident or their representative in writing before a transfer or discharge. For one resident (Res #92) of three sampled for discharges, a nurse’s note dated 01/03/26 at 11:23 a.m. documented that the resident was sent to an acute care hospital for behaviors, but there was no written notice of transfer provided prior to this transfer. During an interview on 02/11/26 at 1:19 p.m., an LPN stated they had not heard of a written notice of transfer and had never given such a notice to any residents they had transferred or discharged. In a separate interview on 02/11/26 at 1:22 p.m., the DON stated they were unaware of the requirement for a written notice of transfer to be given to a resident or their representative prior to transfer or discharge and acknowledged that the facility had not been providing these notices to residents. The DON identified that 60 residents had been discharged during the three months prior to the survey, indicating that the lack of written transfer or discharge notices extended beyond the single sampled resident and reflected a broader practice consistent with the incomplete policy and staff unawareness of the requirement.
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