Failure to Communicate Required Resident Information During Transfers
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider during facility-initiated transfers for two of three sampled residents. For one resident with diagnoses including high blood pressure, anemia, and hyperlipidemia, there was no documented evidence that the facility provided the receiving hospital with required information such as care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs. This lack of documentation was confirmed by the Director of Nursing. Similarly, another resident with diagnoses of high blood pressure, delirium due to a known physiological condition, and altered mental status was transferred to the hospital without documented evidence that the required information was communicated to the receiving provider. The Assistant Director of Nursing confirmed that the facility did not ensure the necessary resident information was provided for these two residents as required by regulation.