Failure to Send Advance Directive During Resident Transfer
Penalty
Summary
The facility failed to ensure that a resident's advance directive was sent with them during a transfer to the hospital. According to facility policy, advance directive information should be communicated to the receiving provider when a resident is transferred or discharged. In this case, a resident experiencing labored breathing and coughing up thick green phlegm was transferred to the hospital. Although the face sheet and medication list were sent, the signed advance directive was not included. Hospital staff subsequently had to call the facility to request a copy of the advance directive, confirming that it was not provided at the time of transfer. Interviews with the DON and an LPN confirmed that the advance directive should have been sent but was omitted.