Failure to Communicate MDRO Status During Resident Transfers
Penalty
Summary
The facility failed to ensure that the MDRO (Multi-Drug Resistant Organism) colonization status, special instructions, or precautions for ongoing care were communicated to the receiving hospital at the time of transfer for two residents. In both cases, the residents had documented MDROs, including ESBL Klebsiella and MRSA, as confirmed by laboratory results and the facility's MDRO log. Despite this, nursing notes and transfer documentation did not indicate that this information was shared with the hospital during the transfer process. The facility's process relied on verbal communication, but there was no documentation to confirm that the MDRO status or necessary precautions were conveyed to the hospital. For both residents, the face sheets provided at transfer did not include MDRO diagnoses, and the electronic transfer/discharge documentation was not utilized. Interviews with facility staff, including the Infection Preventionist, DNS, and Regional Nurse, confirmed that the required information was not documented or retained. Additionally, the facility's policy on MDRO control did not specify the requirement to notify the hospital upon transfer, and the policy on MRSA only partially addressed inter-agency notification. These actions and omissions led to the deficiency in communicating critical infection control information during resident transfers.