Failure to Document Transfer/Discharge and Notify Resident of Rights
Penalty
Summary
The facility failed to properly document the transfer and discharge process for one resident who was transferred to an acute care hospital. The facility's policy requires a physician's order for emergency transfers, documentation of the reason for transfer, notification of the resident and their representative, and provision of information such as diagnoses, medications, and the bed hold policy. In this case, the resident, who was cognitively intact and required substantial assistance with activities of daily living, experienced stomach pain and bowel issues. Although the nurse practitioner was notified and treatment was provided, there was no documentation of a change in condition warranting transfer, no physician's order for the transfer, and no evidence that the resident's responsible party was notified. Interviews with facility staff, including the DON and ADON, confirmed that required documentation and notifications were missing from the resident's electronic medical record. Staff were unable to locate records of the transfer order, the reason for transfer, or evidence that the bed hold policy and appeal rights were communicated to the resident or their representative. The facility's failure to follow its own transfer and discharge policy resulted in the resident and their representative potentially being uninformed about the transfer process and their rights.