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 to the hospital. The deficiency was identified through a review of clinical records and staff interviews, which revealed that the facility did not document or convey essential information such as care plan goals, advanced directive information, specific instructions for ongoing care, and resident representative information. Resident R80, who was admitted to the facility with diagnoses of hypertension, hyperlipidemia, and aphasia, was transferred to the hospital without the required documentation and communication of necessary information. Similarly, Resident R105, diagnosed with anxiety, bipolar disorder, and depression, was transferred without the facility providing the receiving provider with the necessary details to ensure continuity of care. Resident R124, who had a history of high blood pressure, stroke, and hemiplegia, was also transferred to the hospital without the facility communicating the required information. The Director of Nursing confirmed the facility's failure to communicate the necessary resident information for these transfers, which was a violation of the facility's policy and regulatory requirements.
Plan Of Correction
Resident R80 and Resident R124 both returned to the facility and experienced no negative outcome from the deficient practice. Resident R105 did not return. Nursing staff will be educated on the need to transfer Residents with specific healthcare information to meet the resident's specific needs including the Resident's Representative, advanced directives, care plan goals, and specific instructions to provide for his/her care needs. Nursing staff will be required to document in the medical record that upon discharge, Residents were transferred with healthcare related documents including healthcare information to meet the resident's specific needs, the Resident's Representative, advanced directives, care plan goals, and specific instructions to provide for his/her care needs. The DON will review all transfers daily at the clinical meeting to ensure the documentation was completed. The DON will report Resident transfers monthly to the QAPI committee including the healthcare information that was sent with the Resident.