Failure to Communicate Resident Information During Transfers
Penalty
Summary
The facility was found to be non-compliant with the requirements for transfer and discharge under 42 CFR Part 483, Subpart B, as well as the 28 Pa. Code, during an abbreviated survey conducted in response to complaints and an infection control survey. The deficiency was identified in the facility's failure to communicate necessary resident information to the receiving health care provider for two residents who were transferred to the hospital. This lack of communication included the omission of critical details such as care plan goals, advanced directive information, specific instructions for ongoing care, and resident representative information. The first resident, admitted to the facility in January 2025, had a medical history that included high blood pressure, diabetes, and cerebral infarction. This resident was transferred to the hospital shortly after admission, but the facility did not document or communicate the necessary information to the hospital, which was essential for the resident's continued care. Similarly, the second resident, admitted in October 2023, with diagnoses of depression, dementia, and Parkinson's disease, was also transferred to the hospital without the required documentation and communication of care details. During an interview, the Director of Nursing confirmed the facility's failure to ensure that the necessary information was communicated to the receiving health care provider for both residents. This oversight was a direct violation of the regulatory requirements for transfer and discharge, as it did not provide the receiving facility with the information needed to meet the residents' specific needs and ensure a safe and effective transition of care.
Plan Of Correction
1. Residents R1 returned to the facility on 1/15/25 and discharged home with family on 2/3/25, and R2 returned to the facility on 1/27/25. 2. A one-week retroactive review of all facility-initiated transfers will be followed-up by telephone to ensure that all necessary resident information was communicated to the receiving health care provider and provide any information if necessary. 3. The NHA or designee will educate all licensed nursing staff and social services staff on the necessary information requirement found at F622 for transfers to a receiving health care provider. 4. The NHA or designee will audit all facility-to-facility transfers to ensure all resident information requirements were met daily x3, then five resident facility-to-facility transfers weekly x8. Results will be reviewed through QAPI for further recommendation.