Failure to Document Necessary Transfer for Resident
Penalty
Summary
The facility failed to ensure that a resident's transfer to the hospital was necessary and properly documented. Resident R 212 was admitted with multiple diagnoses, including mood disorder, dementia, and bipolar disorder. During the resident's five-day stay, there were instances of refusal of care, medication, and food, as well as episodes of agitation and verbal aggression. Despite these behaviors, the facility's documentation did not provide sufficient evidence that the transfer was necessary for the resident's welfare or that the facility could not meet the resident's needs. The nursing notes indicated that the resident refused medications and care, and a psychological consultation resulted in a new medication order. However, the documentation lacked details on specific safety concerns or attempts by the facility to address the resident's needs. The decision to transfer the resident to the hospital was made without clear evidence of endangerment to the resident or others, and the transfer form was incomplete, stating only 'reason for transfer' without further explanation. Interviews with staff, including a licensed nurse and the Director of Nursing, revealed that the resident was discharged due to aggressive behavior and refusal of care. However, the facility was unable to provide evidence that the transfer was necessary for the resident's welfare or that the health and safety of individuals at the facility were endangered. The Director of Nursing admitted that the facility was unwilling to continue providing care to the resident, highlighting a failure to comply with regulatory requirements for transfer and discharge documentation.
Plan Of Correction
1. R212 is no longer a resident at the facility. 2. An audit was completed for residents that transferred to the hospital from 12/1/24 to 2/6/2025 to ensure that the transfer to the hospital was necessary, and the basis for the transfer was documented. 3. Education was completed with the licensed nurses on the requirements for ensuring a facility-initiated, resident transfer to the hospital is necessary, and the basis for the transfer is documented. 4. The DON/Designee will audit resident transfers to the hospital weekly x 4 weeks then monthly x 2 months to assure that a facility-initiated transfer to the hospital was necessary and the basis for the transfer is documented. Findings of the audits will be reported to monthly QA x3.