Deficiencies in Transfer Notice Compliance
Summary
The facility failed to comply with the notice requirements before transferring or discharging residents, as outlined in 42 CFR Part 483, Subpart B. Specifically, the facility did not provide adequate notice of transfer for two residents who were hospitalized, and the notices for five other residents lacked required information. The deficiencies were identified during a review of clinical records and staff interviews. Resident 1, diagnosed with heart failure, chronic kidney disease, and hyperlipidemia, was transferred to the hospital due to an acute medical change. The notice provided to Resident 1's representative was missing several required mailing addresses, including those for the entity receiving appeal requests and the Office of the State Long-Term Care Ombudsman. Similar deficiencies were found in the notices for Residents 28, 52, 58, and 69, who were also transferred to hospitals for various medical conditions, including dementia, hypertension, and heart failure. Additionally, Resident 28's clinical record lacked a notice of transfer for one of their hospitalizations, and Resident 53's record showed no evidence of a transfer notice being provided for a hospital evaluation following a fall. Interviews with the Nursing Home Administrator and Director of Nursing confirmed the absence of required information on the transfer notices and the failure to provide proper documentation for some transfers.
Plan Of Correction
1. Unable to retroactively correct the clinical record for Residents 1, 28, 52, 53, and 58 with a notice upon transfer that included required and revised information. All residents continue to reside at the facility. R69 no longer resides at the facility, no adverse effects related to practice. 2. All residents have the potential to be impacted. R1, R28, R52, R53, and R58 will be given the revised Transfer or Discharge form with the appropriate notice of information no later than March 14, 2025 for any immediate Transfer or Discharge, along with a facility-wide audit conducted by the DON and Shift Supervisors. 3. DON will educate the Shift Supervisors by March 14, 2025 upon emergent transfer to the hospital and will provide the revised Notice of Resident Transfer or Discharge form to resident and document in a progress note via the EHR system (PCC) to reflect it was presented with appropriate information. The Shift Supervisor is to then complete a progress note documenting the notice was provided and to whom. The DON will also educate Shift Supervisor on the updated Notice of Resident Transfer on Discharge form, and to provide the Notice of Resident Transfer to Discharge Form to the Resident revealing the mailing address of the entity, which receives request for appeals, mailing address of the Office of the State Long Term Care Ombudsman for protection and advocacy of individuals with developmental disabilities and mental disorders. The DON will in-service the Shift Supervisors by March 14, 2025 to ensure the representative is provided the notice and signed the form when received. DON will also educate the Social Worker by March 14, 2025 to send a 30-day log of transfer and discharges to the local Ombudsman's email box. 4. Social Worker Director and DON will conduct a record audit via the progress notes of all residents who have emergent transfer to the hospital and audit the transfer and discharge log to be sent to the Ombudsman daily x 3 to ensure the Notice of Residents Transfer or Discharge information contained appropriate information and was given and signed appropriately, to whom until 100% completion is achieved. Audits will continue x2 weekly, until 100% is achieved. Findings of the audits will be reported monthly to the QAPI committee meeting to ensure compliance is obtained and maintained.
Penalty
The facility did not issue written transfer or discharge notices to two residents or their legal representatives before transferring them to an acute care hospital. Documentation for both cases lacked evidence of the required notifications, and this was confirmed by the Market Clinical Advisor during the survey.
Facility staff did not provide required notifications to the ombudsman or written notices to residents and their representatives during transfers or discharges to hospitals. In several cases, residents with varying levels of cognitive impairment were transferred without proper documentation or notification, and staff interviews revealed a lack of awareness of these requirements.
A resident was transferred to the hospital for evaluation of shortness of breath, but the facility did not notify the ombudsman as required. The NHA stated they were unaware of the notification requirement, and this deficiency was identified through interviews and record review.
The facility did not notify the State Long-Term Care Ombudsman of hospital and ED transfers for two residents, as required by policy. One resident's hospital transfer and another resident's two ED transfers were omitted from the monthly reports, with staff confirming these events were not reported due to oversight and lack of awareness of notification requirements.
A resident with End Stage Renal Disease and Dependence on Renal Dialysis was transferred to the hospital and later returned, but the transfer was not documented in the Emergency Transfer Log or reported to the State LTC Ombudsman as required. Both the Social Service Director and Administrator confirmed the omission during interviews and record reviews.
Staff did not provide written notification to a resident and their representative upon the resident's transfer to the hospital, instead relying solely on verbal communication as confirmed by both an RN/Unit Supervisor and an LPN.
Failure to Provide Written Transfer/Discharge Notices Prior to Hospital Transfers
Penalty
Summary
The facility failed to provide written transfer or discharge notices to residents or their legal representatives prior to facility-initiated transfers to an acute care hospital. Specifically, documentation for two residents showed that each was transferred and subsequently admitted to a hospital, but there was no evidence in their clinical records that a written notice of transfer or discharge was issued to them or their legal representatives. This deficiency was confirmed during an interview with the Market Clinical Advisor, who was unable to locate the required transfer/discharge forms for these residents at the time of their transfers.
Failure to Notify Ombudsman and Provide Written Transfer/Discharge Notices
Penalty
Summary
Facility staff failed to provide timely and appropriate notification to residents, their representatives, and the Office of the State Long-Term Care Ombudsman prior to or at the time of transfer or discharge for multiple residents. In several cases, there was no evidence that the ombudsman was notified when residents were transferred to local hospitals or higher levels of care. Staff interviews revealed a lack of awareness regarding the requirement to notify the ombudsman, and documentation supporting such notifications was not provided to surveyors upon request. For one resident with intact cognition, there was no documentation that the ombudsman was notified of the resident's transfer to a hospital. Another resident, who was severely cognitively impaired, was sent to an acute care hospital without evidence of ombudsman notification, and the social worker confirmed she was unaware of the notification requirement. Additionally, a resident with severe cognitive impairment was transferred to a hospital, and again, no evidence of ombudsman notification was found. In another instance, a resident and their representative did not receive written notice of the reason for transfer/discharge, nor was the ombudsman notified. The facility's own policy indicated responsibilities for informing appropriate parties of transfers or discharges, but staff interviews and document reviews showed these procedures were not followed. The survey team discussed these deficiencies with facility leadership, but no further evidence of compliance was provided before the survey exit.
Failure to Notify Ombudsman of Resident Hospital Transfer
Penalty
Summary
The facility failed to notify the ombudsman of a resident's transfer to the hospital, as required by federal and state regulations. A resident reported having recently returned from the hospital, and a review of their progress notes confirmed a documented transfer for further evaluation of shortness of breath. During an interview, the Nursing Home Administrator acknowledged being unaware of the requirement to notify the ombudsman about such transfers. This deficiency was identified through resident interview, record review, and staff interview, and was evident for one resident reviewed for hospitalizations.
Failure to Notify Ombudsman of Resident Hospital and ED Transfers
Penalty
Summary
The facility failed to notify the State Long-Term Care Ombudsman of hospital and emergency department (ED) transfers for two residents, as required by facility policy. One resident experienced a change in condition and was transferred to the hospital, but this transfer was not included in the monthly report sent to the Ombudsman. The omission was confirmed by the staff member responsible for submitting these reports, who acknowledged that the transfer should have been reported. Another resident was transferred to the ED on two separate occasions due to changes in condition and returned to the facility the same days. These ED transfers were also not included in the monthly report to the Ombudsman. The staff member responsible for notifications indicated a lack of awareness that ED transfers required notification to the Ombudsman, resulting in these events not being reported as mandated by facility policy.
Failure to Notify Ombudsman of Facility-Initiated Transfer
Penalty
Summary
The facility failed to notify the State Long Term Care Ombudsman of a facility-initiated transfer for one resident. The resident, who had diagnoses including End Stage Renal Disease and Dependence on Renal Dialysis, was initially admitted on 08/29/2024 and re-admitted on 04/15/2025. Nurse's notes documented that the resident was transferred to the hospital on 03/30/2025 and returned to the facility on 04/15/2025. However, a review of the Emergency Transfer Log for March and April 2025 showed that this transfer was not recorded. During interviews and record reviews with the Social Service Director and the Administrator, both confirmed that the resident's transfer to the hospital was not included in the notification list sent to the State Long Term Care Ombudsman, as required. The Social Service Director acknowledged responsibility for completing and sending the Emergency Transfer Log and confirmed the omission. The Administrator also confirmed that the Ombudsman was not notified of the facility-initiated transfer, which should have occurred.
Failure to Provide Written Notification of Resident Transfer
Penalty
Summary
Facility staff failed to provide written notification of transfer to a resident and their responsible representative when the resident was hospitalized. Record review showed that the resident was transferred to the hospital, and interviews with both a Registered Nurse/Unit Supervisor and a Licensed Practical Nurse confirmed that only verbal notification was given to the resident's representative regarding the transfer and its reasoning. There was no evidence that written notification was provided as required.
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