Failure to Document Required Information During Resident Hospital Transfers
Penalty
Summary
The facility failed to ensure that services provided consistently met professional standards of practice for two of four sampled residents who were reviewed for hospitalizations. Specifically, the facility did not complete required hospital transfer documentation for these residents, omitting critical information such as the basis for hospital transfer, specific resident needs that could not be met by the facility, attempts made by the facility to meet those needs, services available at the receiving hospital, and details of information conveyed to the receiving provider. This lack of documentation was identified through observation, interviews, and record review. For one resident with complex medical conditions including cancer, hypertension, and a pacemaker, there was no documentation of the nurse's assessment prior to hospital transfer, the care needs identified, discussions with the resident, the reason for transfer, notifications to the provider or emergency contacts, or information sent to the hospital. The facility's policy required timely and comprehensive documentation of resident status, needs, and services, but these requirements were not met in this case. Staff interviews confirmed that the expected documentation, including use of the Emergent Transfer form and detailed progress notes, was not completed. Another resident with severe cognitive impairment and behavioral issues was transferred to the hospital multiple times for various reasons, including falls and combative behaviors. In several instances, documentation was missing regarding the specific needs the facility could not meet, attempts to address those needs, services available at the hospital, and information conveyed to the receiving provider. Staff acknowledged these omissions during interviews and confirmed that the required documentation was not consistently completed for hospital transfers.