Failure to Document Reason for Hospital Transfer
Summary
The facility failed to document the reason for a resident's transfer to the hospital emergency department in the resident's medical record, as required by federal regulations. The resident in question was a 72-year-old individual with multiple diagnoses, including liver cirrhosis, chronic congestive heart failure, chronic kidney disease, and diabetes. The resident was cognitively intact, as indicated by a BIMS score of 13. On the date of the incident, the resident requested to be sent to the emergency department for evaluation, and the facility arranged for transport after obtaining an order from the on-call healthcare provider. A review of the resident's electronic medical record revealed that, aside from a progress note stating the resident requested to go to the emergency department, there was no documentation indicating the specific reason for the transfer. There was no transfer form, physical assessment, physician communication note, or physician note explaining the medical necessity or rationale for the transfer. The facility's documentation did not provide any further details beyond the resident's request. During interviews, the DON confirmed that a transfer form was not completed for this resident, as the form was a recent addition to their processes. The DON also stated that no assessment was performed prior to the transfer because the resident requested to go, and it was the facility's practice to send residents to the emergency department upon request, regardless of medical necessity. This lack of documentation and assessment led to the deficiency cited by surveyors.
Plan Of Correction
F623 1. Resident #47 no longer resides in the facility, an investigation of the event was completed and the licensed nurse involved received education on appropriate assessment, notification, and documentation of transfers. 2. Like residents are identified as those who are emergently transferred to the hospital. A sweep of like residents for the last 2 weeks was completed by 4/23/2025 to ensure appropriate documentation of the reason for transfer was in place. A Transfer form was added to the facility's EMR system to guide the licensed nurses in appropriate documentation. 3. Licensed nurses were educated on the use of the new Transfer form in PCC to complete which includes, appropriate assessment, notifications, and documentation for all residents who require emergent transfer to a hospital. 4. The QAPI Committee has directed the DON and/or designee to ensure that weekly audits are completed on residents who are transferred out emergently, to ensure the appropriate assessment, notifications, and documentation is completed. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review.
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.
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.
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.
Facility staff did not provide written notification to the State Long-Term Care Ombudsman when a resident, who was cognitively intact and required assistance with self-care, was discharged to the hospital. The Social Services Director confirmed there was no documentation of notification, and facility leadership did not offer further comments on the matter.
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 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 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 Resident Hospital Discharge
Penalty
Summary
Facility staff failed to provide written notification to the Office of the State Long-Term Care Ombudsman regarding the hospital discharge of a resident. The deficiency was identified through resident record review, staff interviews, and examination of facility documents. The resident involved had a history of atherosclerosis, diabetes, and chronic kidney disease, and had recently undergone a right above the knee amputation. The resident was cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status (BIMS), and required varying levels of assistance with self-care activities as documented in the Minimum Data Set (MDS) assessment. Nursing notes indicated the resident was admitted to the hospital following a vascular appointment and was expected to remain hospitalized for at least a week. Despite this, there was no documentation that the Ombudsman was notified of the resident's discharge to the hospital. The Social Services Director confirmed the lack of notification and was initially unaware that this responsibility fell under her role at the facility. During a final interview, facility leadership did not provide additional comments or concerns regarding the incident.
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