Failure to Communicate Resident Information During Transfers
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider during facility-initiated transfers for two residents. According to the facility's policy on Transfer and Discharge, specific information must be provided to the receiving provider, including contact information of the resident's practitioner, resident representative information, and all other necessary details to meet the resident's needs. However, for Resident R18, who was transferred to the hospital, there was no documented evidence that the facility communicated the resident's care plan goals, advanced directive information, specific instructions for ongoing care, and other necessary information to the receiving provider. Similarly, Resident R47 was transferred to the hospital, and the facility failed to document the communication of essential information to the receiving health care provider. This included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, and resident representative information. The Director of Nursing confirmed that the facility did not ensure the necessary resident information was communicated for both residents as required by the facility's policy and state regulations.
Plan Of Correction
MD was retroactively notified regarding change of condition for R18 and R47. Whole house audit completed to ensure no additional residents were affected. Nursing staff and social worker will be educated on sending necessary health information to a receiving health care facility when residents are transferred to an alternate setting by 2/11/2025. Audit will be conducted by DON or designee on sending necessary health information to a receiving health care facility when residents are transferred to an alternate setting weekly x 1 week and monthly x 1 month.