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 two residents who were transferred from the facility. Resident R47, who had diagnoses of intellectual disabilities, dementia, and major depressive disorder, was transferred to the hospital after exhibiting symptoms such as elevated blood pressure, right-sided facial droop, and left arm weakness. Despite the transfer, there was no documented evidence that the facility communicated the resident's care plan goals, advanced directive information, or specific instructions for ongoing care to the hospital. Similarly, Resident R76, who had diagnoses of high blood pressure, depression, and dementia, was transferred to the hospital due to elevated blood pressure and a headache. The facility also failed to document the communication of necessary information to the receiving health care provider, including the resident's care plan goals, advanced directive information, and resident representative information. During an interview, the Nursing Home Administrator confirmed the lack of evidence that the necessary information was communicated to the receiving health care institution for these two residents. This deficiency was identified based on a review of facility policies, resident records, and staff interviews.
Plan Of Correction
1. The facility is unable to go back and make certain that specific information was communicated to the receiving health care provider during resident transfers. 2. DON/designee to educate licensed staff on comprehensive transfer protocol regarding providing specific information to receiving health care provider and appropriate documentation on the event. 3. DON/designee to audit hospital transfers to ensure proper documentation is sent 5x/week for 2 weeks, then 3x/week for 2 weeks, and 1x/week for 2 weeks. 4. Results to be submitted to QAPI for review and approval.