Incomplete Transfer Documentation for Resident
Penalty
Summary
The facility failed to ensure the New Jersey Universal Transfer Form (UTF) was completed when transferring a resident to another long-term care facility. Specifically, for Resident #289, only 9 out of the 29 required sections of the UTF were filled out, leaving critical areas such as code status, reason for transfer, and medical records attachments blank. Additionally, the facility did not complete the physician discharge summary for the resident, which is a necessary document to accompany the transfer. Resident #289 was admitted with diagnoses including cerebral infarct, hemiplegia, hemiparesis, and dysphagia. The resident was transferred to a facility closer to a family member, but the transfer documentation was incomplete. The Director of Nursing and the Licensed Nursing Home Administrator acknowledged the deficiencies in the UTF and the absence of a discharge summary during the surveyor's review.
Plan Of Correction
1. Resident affected by the deficient practice: The facility failed to ensure the New Jersey Universal Transfer form and physician discharge summary was completed for resident #289. Resident #289 was discharged from the facility [R]. Individual nurse who discharged the resident was provided with individual education on the process for discharging residents to another LTC facility, including the New Jersey Universal Transfer Form. 2. Identifying other residents who could be affected by the deficient practice: Residents being discharged to another LTC facility could be affected by this deficient practice. Discharges for December were audited and no residents were discharged from the facility to another LTC during this period. 3. Measures or systemic changes to ensure that the deficiencies will not recur: Licensed Nurses and U.S. FOIA (b) (6) were in-serviced on the policy/process for discharging residents to another facility that includes the New Jersey Universal Transfer Form, beginning 12/4/24 by the Director of Nursing and Assistant Director of Nursing. The Clinical Management team and The Medical Records Director in-serviced on completion of Physician discharge summary for all residents discharged, beginning on 12/4/24 by the Director of Nursing and Assistant Director of Nursing. 4. Monitoring the continued effectiveness of the systemic change: The Director of Nursing or Designee will conduct audits of discharged residents charts to ensure accurate completion of the New Jersey Universal transfer form and discharge summaries weekly x 4 weeks then monthly x 2 months. Results of the audit will be reviewed at the Monthly Quality Assurance Meeting and Quarterly over the duration of the audit process to ensure compliance and reassessed for further action.