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 this deficiency were transferred to the hospital, but there was no documented evidence that the facility had communicated essential information such as care plan goals, advanced directive information, specific instructions for ongoing care, and resident representative information to the receiving health care provider. Resident R70, who was admitted to the facility with diagnoses including cancer, depression, and peripheral vascular disease, was transferred to the hospital. However, the clinical record lacked documentation of the necessary information being communicated to the hospital. Similarly, Resident R76, with diagnoses of high blood pressure, depression, and diabetes, was transferred without the required documentation. Resident R115, admitted with renal insufficiency, atrial fibrillation, and heart failure, also had no documented evidence of communication of necessary information upon transfer. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed the facility's failure to document and communicate the required information for these residents' transfers. The Nursing Home Administrator acknowledged that while paperwork was sent with the residents, there was no documentation to prove what was sent. This lack of documentation and communication led to the identified deficiency.
Plan Of Correction
Residents R70 remains in facility with no negative outcomes. R76 remains in facility with no negative outcomes. R115 has been discharged. A one-week retroactive review of all facility-initiated transfers will be followed by telephone to ensure that all necessary resident information was communicated to the receiving health care provider and provided if necessary. The DON/Designee will educate all licensed nursing on the necessary information requirement found at F622 for transfers to a receiving healthcare provider. 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.