Failure to Communicate Resident Information During Transfer
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider during a facility-initiated transfer. This deficiency involved a resident who was originally admitted with diagnoses including surgical aftercare, muscle weakness, and venous insufficiency. The resident was transferred to the hospital and did not return to the facility. Upon review, there was no documented evidence that the facility communicated essential information such as the resident's care plan goals, advanced directive information, specific instructions for ongoing care, and resident representative information to the receiving health care provider. The Director of Nursing confirmed this failure during an interview.
Plan Of Correction
The facility submits this plan of correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges are deficient under State and Federal regulations relating to long term care. This plan of correction should not be construed as either a waiver of the Facility's right to appeal and to challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violations of State and Federal regulatory requirements. Any resident transferred or discharged to the hospital after 1/9/2025 was audited to ensure all required documentation was transferred with the transferred resident. R52 was not affected by the deficient practice of not providing documentation at the time of transfer to the hospital. All discharged residents had the potential to be affected by the deficient practice; however, there were no known negative outcomes. The DON/ Designee will educate nursing staff on including the correct documentation of resident care in the transfer process for the accepting healthcare provider. The DON/Designee will conduct daily audits for four weeks to ensure resident documentation regarding their plan of care is included in the transfer process of all residents who are transferred to another healthcare provider for further care. The results of audits will be submitted to the QAPI committee to review for any trends that require further recommendation follow up.