Deficiencies in Transfer and Discharge Notice Procedures
Summary
The report identifies deficiencies in the handling of Nursing Home Transfer and Discharge Notices for residents being transferred to acute care facilities. Specifically, the facility failed to provide timely and complete discharge notices to residents and their representatives. In the case of Resident #11, the notice was signed by the Social Service Director (SSD) and the resident, but the Nursing Home Administrator expressed uncertainty about how residents could sign the notice during emergency transfers. Similarly, for Resident #60, the notice lacked a brief explanation to support the transfer action and did not include resident representative information. The SSD admitted that notices were often completed after the resident returned from the hospital, due to the emergency nature of the transfers. The facility's policy on transfer and discharge requires that residents and their representatives be notified in writing of the reasons for transfer or discharge. However, the SSD acknowledged that in 9 out of 10 cases, the transfer was an emergency, and the resident or family was not present to sign the notice. The SSD also mentioned that the notices were typically uploaded into resident records but might still be in the office. The facility's policy allows for immediate notice in cases where the resident's urgent medical needs require a transfer, but the report indicates that the facility did not consistently adhere to this policy, resulting in incomplete and delayed notifications.
Plan Of Correction
Do a weekly audit for 12 weeks on a minimum of 3 discharged residents each week. Otherwise, if the facility doesn't have at least 3 discharges per week, the Social Service Director/designee will complete the weekly audit on the number of discharges the facility has for that week. This weekly audit will be done to ensure that the facility provided discharged residents the Nursing Home Transfer and Discharge Notice form per the facility policy. The Social Service Director or designee will review the audits with the monthly Quality Assurance Performance Improvement Committee for three months. The Quality Assurance and Performance Improvement Committee will evaluate the outcome of the audits and if necessary, amend the improvement plan and continue to monitor until substantial compliance has been determined by the committee.
Penalty
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