Failure to Provide and Document Required Written Transfer/Discharge Notices to Residents and Representatives
Penalty
Summary
The deficiency involves the facility’s failure to provide required written Transfer and Discharge Notices, including bed-hold and return policies, directly to residents and/or their representatives when residents were transferred to an acute care hospital. Surveyors cited SOM Appendix PP, F483.15(c)(3), which requires that before a transfer or discharge, the facility must notify the resident and the resident’s representative in writing and in a language and manner they understand. The facility’s own policy dated 10/2022 states that notice of transfer is to be provided to the resident and representative as soon as practicable before transfer, and that notice of bed-hold and return policies must be provided within 24 hours of an emergency transfer, with documentation in nursing notes of appropriate orientation and preparation of the resident. For one resident with severe cognitive impairment (BIMS score 0) who fell and had hypotension, the progress notes showed the responsible party was at the bedside during the transfer to the hospital. The Notice of Transfer and Discharge dated the same day was completed by an LVN and indicated that a written copy was provided to the responsible party, but the method documented was that it was sent with transfer paperwork to the acute hospital via paramedics. For a second resident, who had capacity to understand and make decisions and experienced a sudden change in mental status leading to transfer, the Notice of Transfer and Discharge was completed by an RN and also indicated that a written copy was provided to the responsible party, yet again the method documented was that it was sent with the transfer paperwork to the acute hospital. For a third resident with moderate cognitive impairment (BIMS score 9) who was transferred to the hospital after a fall with injury and later readmitted, the Notice of Transfer and Discharge completed by an RN had the section for “Written copy of the Notice of Transfer and Discharge Provided” left blank, while the method section showed it was sent with transfer paperwork to the acute hospital. During interviews, the DON and nursing staff described a practice of placing the Notice of Transfer and Discharge, along with other clinical documents, in an envelope given to paramedics for the hospital, while verbally informing residents or responsible parties of the transfer and bed-hold. The DON acknowledged that the notice, discharge, and bed-hold information were on one form and that the facility relied on verbal notification, and the RN who transferred one resident stated she verbally informed the responsible party and handed the notice to him but did not document this in the medical record. Another LVN stated she sent the notice with the hospital transfer records and did not confirm awareness of the facility’s policy, resulting in a lack of documented evidence that written notices were actually provided to the residents or their representatives as required.
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