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 for three residents who were transferred from the facility. This deficiency was identified through a review of clinical records and staff interviews. The residents involved in the transfers were identified as having various medical conditions, including high blood pressure, hip fracture, malnutrition, Alzheimer's Disease, and dementia. For Resident R21, who was admitted to the facility in September 2022 and transferred to the hospital in October 2024, there was no documented evidence that the facility communicated essential information such as care plan goals, advanced directive information, and specific instructions for ongoing care to the receiving health care provider. Similarly, Resident R30, admitted in January 2021 and transferred in February 2024, also lacked documentation of communicated information necessary for their care at the receiving facility. Resident R78, admitted in October 2023 and transferred in December 2024, was also affected by this deficiency. The clinical record review revealed that the facility did not document the communication of critical information, including care plan goals and resident representative information, to the receiving health care provider. The Director of Nursing confirmed the absence of this documentation during an interview, highlighting the facility's failure to meet regulatory requirements for resident transfers.
Plan Of Correction
Facility is unable to retroactively make corrections for Residents #21, #30 and #78. Moving forward the facility will make certain the necessary resident information is communicated to the receiving health care provider. To identify other residents, the DON/designee performed a house audit on transfer and discharge from 1/16/2025 to present to ensure the necessary resident information is communicated to the receiving health care provider. There were no negative findings. To prevent this from recurring, the RDCS provided education to the nursing staff on the regulatory requirements of F0622, for transfer and discharge documentation ensuring necessary resident information is communicated to the receiving health care provider, which includes resident care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and resident specific needs. To monitor and maintain ongoing compliance, the DON/designee will audit resident transfers 5 days weekly for 4 weeks, then monthly for 2 months to ensure necessary resident information is communicated to the receiving health care provider. Negative findings will be addressed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.