Failure to Communicate Critical Lab Results During Resident Transfer
Penalty
Summary
Twin Lakes Rehabilitation and Healthcare Center was found to be non-compliant with federal and state regulations regarding the transfer and discharge of residents. Specifically, the facility failed to update the admitting facility with critical laboratory information for a resident who was transferred. The resident, who was cognitively intact and required assistance for daily care, had been diagnosed with debilitating cardiorespiratory conditions and was experiencing recurrent watery stools. A physician ordered a test for Clostridioides difficile (C-diff), which returned positive results. However, there was no documented evidence that this information was communicated to the receiving facility upon the resident's discharge. The deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the lack of documentation regarding the communication of the resident's laboratory results to the admitting facility. This oversight violated the requirements for ensuring a safe and effective transition of care, as outlined in the federal regulations and the Pennsylvania Long Term Care Licensure Regulations. The failure to provide this critical information could potentially impact the ongoing care and safety of the resident at the new facility.
Plan Of Correction
F0622 Transfer and Discharge Requirements 1. Resident 2 no longer resides in the admitting facility that she was discharged to. 2. A 30 day look back audit was completed of discharged residents to ensure that abnormal laboratory results were communicated to the admitting facility. 3. The Director of Nursing or designee will review the Order Entry Report and the laboratory results during clinical meeting to ensure that abnormal results received proximal to date of discharge were communicated to the admitting facility. The Director of Nursing will educate the Intradisciplinary team and Registered Nurse Supervisors to notify the admitting facility of a discharged resident of abnormal laboratory results received proximal to the date of discharge. 4. The Director of Nursing or designee will complete audits to ensure abnormal laboratory results are received for discharged residents are communicated to the receiving facility. This audit will be completed weekly times 4 weeks. The results of the audit will be reviewed at the monthly Quality Assurance Performance Improvement Committee meeting.