Failure to Document and Communicate Transfer/Discharge Information
Penalty
Summary
The facility failed to document complete transfer and discharge information for one resident who was reviewed for the transfer/discharge process. The resident, who had multiple diagnoses including paraplegia and a recent surgical repair of a fractured right femur, was admitted to the facility and later transferred to another long-term care facility after returning from the hospital. The electronic health record contained a progress note indicating the transfer, but there was no transfer form to the hospital, no discharge plan, summary note, or progress notes to indicate that instructions had been given to the receiving hospital or LTC facility regarding the resident's ongoing healthcare needs. Interviews with the DON and NHA confirmed that there was no transfer or discharge summary for the resident, and that the required information had not been provided to the receiving healthcare providers. The facility's own policies require that transfer/discharge notices and discharge planning documentation be completed and communicated to the resident, their representative, and the receiving provider, but these steps were not documented in this case.