Failure to Communicate Required Clinical Information During Resident Transfer
Penalty
Summary
Pleasant Ridge Manor West was found to be noncompliant with federal and state regulations regarding the discharge process for residents. The facility's policy requires that, upon transfer or discharge, necessary resident information must be communicated to the receiving health care provider and documented in the resident's medical record. However, a review of the clinical record for one resident revealed that this process was not followed. The resident in question had an admission date of 12/12/24 and diagnoses including respiratory failure, congestive heart failure, and obstructive sleep apnea. On 5/15/25, a progress note indicated that the resident was transferred to the hospital. Despite this transfer, the clinical record did not contain evidence that the necessary clinical information was communicated to the receiving health care provider as required by both facility policy and federal regulations. During an interview, the DON confirmed that there was no documentation showing that the required clinical information was provided to the hospital at the time of transfer. The DON also acknowledged that it is the facility's expectation and policy to provide and document such information during resident transfers. This failure constituted a deficiency in meeting the requirements for safe and effective resident discharge and transfer communication.
Plan Of Correction
Preparation and/or evaluation of the following Plan of Correction set forth in these documents does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusion set forth in the Statement of Deficiency. The Plan of Correction is prepared and/or executed solely because it is required by the provisions of federal and state law. Registered Nurse's User Defined Assessment/Transfer Assessment was created to ensure that all pertinent information is relayed to the receiving provider. All Registered Nurse Supervisors will be educated on completing this assessment and documenting that Physician/Resident Representative were notified. All licensed staff will be educated on the requirements on the completing the e-interact transfer form, copy of current Medication Administration record, and sending the summary of episode note form. All requirements are captured in the e-interact and/or summary of episode note. The Director of Nursing/Designee will audit daily any resident transfers to ensure all pertinent information is relayed to the receiving provider. Audit will be completed daily for thirty days and if compliant will audit weekly for thirty days and then change to quarterly. Results of these audits will be reviewed at the Quality Assurance Committee meeting monthly for review until audits meet 100% compliance for three consecutive quarters. The Director of Nursing/designee will be responsible for compliance. Completion Date: 7/31/25