Failure to Communicate Required Clinical Information During Resident Transfers
Penalty
Summary
Bradford Manor was found to be noncompliant with federal and state regulations regarding the discharge process, specifically the communication of necessary clinical information to receiving health care providers when residents were transferred to the hospital. The facility's policy requires sufficient preparation to ensure safe and orderly transfers, with documentation in the residents' clinical records. However, for three residents reviewed, the required information was not communicated as mandated. One resident with diabetes and chronic obstructive pulmonary disease (COPD) was transferred to the hospital, but the clinical record did not show that necessary clinical information was provided to the receiving provider. Another resident with peripheral vascular disease, hyperlipidemia, and hypertension was transferred to the hospital on two occasions, and in both instances, the clinical record lacked evidence of communication of essential clinical information to the hospital. A third resident with COPD, hypertension, and heart failure was also transferred to the hospital, and again, the clinical record did not contain documentation that the required information was shared with the receiving provider. During an interview, the Director of Nursing confirmed that the clinical records for these residents did not contain evidence that the necessary clinical information was provided to the receiving health care provider upon transfer. The facility failed to meet the requirements for ensuring that all pertinent information was communicated during resident transfers, as outlined in both federal and state regulations.
Plan Of Correction
This plan of correction has been prepared and executed because the law requires it. This plan does not constitute an admission that any of the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract obligation or position. Bradford Manor reserves the right to raise all possible contestations and defenses in any civil, criminal, claim, action or proceeding. Please accept this plan of correction as Bradford Manor's credible allegation of compliance. Contacted the hospital that a current resident is admitted to and confirmed that they have received all of the resident's medical record information as required. For the identified residents, we interviewed the nurses that transferred them out and confirmed that all required information was communicated and sent with the resident at time of transfer. Those nurses were immediately educated. The E-interact (transfer document used in our electronic health records) is processed and it includes all of the resident's medical records as well as a checklist of all required documents that are to be sent when resident is transferred. This checklist will be signed by the nurse completing the transfer and then placed in the resident's chart. Director of Nursing or designee will provide education to all registered nurses on the requirements of providing and documenting that all necessary resident information sent and communicated with the receiving healthcare provider upon transfer by 8/30/2025. DON will audit 100% of transfers for the past one month, then 50% of transfers for the past one month, and then 25% of transfers for the past one month. All findings will be reviewed at monthly Quality Assurance and Performance Improvement meetings.