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 six residents who were transferred. This deficiency was identified through a review of facility policy, clinical records, and staff interviews. The residents involved in the transfers were expected to return to the facility, yet there was no documented evidence that essential information, such as care plan goals, advanced directive information, specific instructions for ongoing care, and resident representative information, was communicated to the receiving provider. Resident R39, admitted on 9/7/24, was transferred to the hospital on 11/24/24. The clinical record lacked documentation of communication of the resident's care plan goals and other necessary information to the hospital. Similarly, Resident R49, admitted on 2/26/24, was transferred on 11/11/24, and Resident R73, admitted on 6/20/24, was transferred on 7/7/24, both without documented communication of essential information to the receiving health care providers. Additional cases included Resident R169, admitted on 4/10/24 and transferred on 12/2/24, Resident R460, admitted on 12/15/20 and transferred on 2/15/24, and Closed Resident Record CR611, admitted on 7/14/23 and transferred on 12/18/24. In each case, the facility failed to document the communication of necessary information to the receiving health care provider. The Director of Nursing confirmed this failure during an interview, acknowledging that the facility did not meet the required standards for communication during resident transfers.
Plan Of Correction
1. Facility is unable to retroactively correct the deficiency as it relates to R39, R49, R73, R169, R460 and CR611. 2. Director of nursing reviewed facility policy on hospital transfers. Policy was updated to reflect documentation of documents sent to receiving hospital. 3. Director of nursing or designee will in-service licensed staff on completing facility transfer form indicating documents sent to receiving hospital when transferring a resident to an outside hospital. 4. Director of nursing or designee will audit 5 hospital transfers weekly for 2 weeks, then 3 hospital transfers for 2 weeks, then 3 hospital transfers monthly for 2 months to ensure documentation of records sent with resident are present. Audit findings will be shared with QAPI committee.