Failure to Accurately Communicate Code Status and Medical Device During Resident Transfer
Penalty
Summary
The facility failed to accurately communicate a resident's code status and the presence of a medical device during a transfer to an acute hospital. Specifically, the transfer form for a resident with respiratory failure, a tracheostomy, and aphasia indicated a DNR (Do Not Resuscitate) status, while the most current POLST signed by the family member that morning indicated full code status. Additionally, the transfer documentation did not include the type and size of the resident's tracheostomy tube, which was required information for ongoing care. Interviews with facility staff, including the RN, DON, and RT, confirmed that the transfer form should have reflected the resident's current code status and included details about the tracheostomy tube. The facility's own policy required that advanced directive information, resident status, and all special instructions or devices be communicated during transfers. The failure to provide accurate and complete information was identified during a complaint investigation and was supported by a review of the resident's medical record and staff interviews.