Failure to Communicate Resident Information and Provide Physician Discharge Summary
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider during a facility-initiated transfer for one resident. Specifically, for a resident with diagnoses including anemia, dementia, and diabetes, there was no documented evidence that the facility provided the receiving provider with essential information such as care plan goals, advanced directives, specific instructions for ongoing care, resident representative information, and other details required to meet the resident's needs at the receiving facility. This omission was identified during a review of the clinical record following the resident's transfer to a hospital and subsequent return. Additionally, the facility did not provide a discharge summary completed by a physician for another resident who left the facility against medical advice. During a closed record review, it was confirmed by the medical records staff and the Director of Nursing that the discharge summary was missing from the resident's medical record. These findings were based on facility policy review, clinical record review, and staff interviews.