Failure to Document Resident Transfer Following Psychiatric Emergency
Penalty
Summary
A deficiency occurred when the facility failed to ensure proper transfer documentation for a resident with multiple psychiatric and cognitive diagnoses, including anxiety disorder, mood disorder, unspecified psychosis, and dementia with behavioral disturbance. The resident, who had moderate cognitive impairment and used a wheelchair, became increasingly agitated and aggressive, culminating in a physical altercation with staff and an attempt to leave the unit by force. The situation escalated to the point where the resident was administered Haloperidol and transferred to a local hospital on a psychiatric petition. Despite the severity of the incident and the transfer to the hospital, the facility did not complete or include the required transfer documentation in the resident's medical record. The only documentation available was an incident report, which was marked as privileged and confidential and not part of the medical record, and a progress note regarding the administration of Haloperidol. There were no progress notes or late entries detailing the resident's transfer disposition or destination, and the DON confirmed that a hospital transfer notice had not been completed. The facility's own "Transfer and Discharge Guideline" requires documentation of the resident's health status, the basis for transfer, and the services to be provided by the receiving provider. However, these requirements were not met in this case, as the necessary information regarding the resident's health status, safety, transfer arrangement, and destination was missing from the medical record. The deficiency was confirmed during interviews and record review, with facility leadership unable to provide additional documentation.