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 four out of five residents who were transferred from the facility. This deficiency was identified through a review of facility policy, clinical records, and staff interviews. The facility's policy on transfers, dated January 10, 2025, required that specific forms, including the Discharge/Transfer Form, care plan goals, and Bed Hold Notice, be sent with residents during facility-initiated transfers to hospitals. For Resident R26, who was admitted on June 4, 2018, and transferred to the hospital on February 9, 2025, there was no documented evidence that the facility communicated the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and other necessary information to the receiving health care provider. Similar deficiencies were noted for Resident R31, who was admitted on September 13, 2013, and transferred on January 10, 2025; Resident R44, admitted on July 28, 2015, and transferred on January 25, 2025; and Resident R95, admitted on February 12, 2025, and transferred on February 24, 2025. The Director of Nursing confirmed during an interview that the facility failed to communicate the necessary resident information to the receiving health care provider for these four residents. This lack of communication could potentially impact the continuity and quality of care provided to the residents at the receiving facility, as essential information regarding their care needs and medical history was not shared as required by the facility's policy and regulatory standards.
Plan Of Correction
The facility cannot retroactively correct for Resident #26, #31, #44 and #95. Moving forward, the facility will communicate necessary information to the receiving health care provider. To prevent this from recurring, the Regional Director of Clinical Services (RDCS)/designee educated licensed nursing staff on the regulatory requirements of F620. To monitor and maintain ongoing compliance, the DON/designee will audit residents transferred to hospital for Continuation of Care document and bed hold policy 2x weekly x4 weeks, then monthly x 2. Negative findings will be addressed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.