Failure to Document Reason for Hospital Transfer
Penalty
Summary
The facility failed to document the reason for a resident's transfer to the hospital emergency department in the resident's medical record, as required by federal regulations. The resident in question was a 72-year-old individual with multiple diagnoses, including liver cirrhosis, chronic congestive heart failure, chronic kidney disease, and diabetes. The resident was cognitively intact, as indicated by a BIMS score of 13. On the date of the incident, the resident requested to be sent to the emergency department for evaluation, and the facility arranged for transport after obtaining an order from the on-call healthcare provider. A review of the resident's electronic medical record revealed that, aside from a progress note stating the resident requested to go to the emergency department, there was no documentation indicating the specific reason for the transfer. There was no transfer form, physical assessment, physician communication note, or physician note explaining the medical necessity or rationale for the transfer. The facility's documentation did not provide any further details beyond the resident's request. During interviews, the DON confirmed that a transfer form was not completed for this resident, as the form was a recent addition to their processes. The DON also stated that no assessment was performed prior to the transfer because the resident requested to go, and it was the facility's practice to send residents to the emergency department upon request, regardless of medical necessity. This lack of documentation and assessment led to the deficiency cited by surveyors.
Plan Of Correction
F623 1. Resident #47 no longer resides in the facility, an investigation of the event was completed and the licensed nurse involved received education on appropriate assessment, notification, and documentation of transfers. 2. Like residents are identified as those who are emergently transferred to the hospital. A sweep of like residents for the last 2 weeks was completed by 4/23/2025 to ensure appropriate documentation of the reason for transfer was in place. A Transfer form was added to the facility's EMR system to guide the licensed nurses in appropriate documentation. 3. Licensed nurses were educated on the use of the new Transfer form in PCC to complete which includes, appropriate assessment, notifications, and documentation for all residents who require emergent transfer to a hospital. 4. The QAPI Committee has directed the DON and/or designee to ensure that weekly audits are completed on residents who are transferred out emergently, to ensure the appropriate assessment, notifications, and documentation is completed. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review.