Failure to Document and Provide Pertinent Health Information During Resident Transfers
Penalty
Summary
The facility failed to ensure that pertinent health information was provided to the receiving health facility during the transfer of two residents. For one resident with a history of epilepsy and anxiety, there were two separate incidents where the resident became non-responsive and exhibited neurological symptoms, prompting transfer to the hospital. In both cases, although the resident’s representative was notified and transfer forms were completed, there was no documentation in the medical record that pertinent medical information was provided to the receiving hospital at the time of transfer. A staff member later confirmed that while the required forms were sent and a report was called in, this was not documented as required. Another resident, who had multiple diagnoses including partial paralysis, dementia, cirrhosis, depression, and anxiety, was transferred to the hospital after sustaining a fall resulting in a head laceration and rib fracture. The resident’s record did not include documentation of the hospital transfer paperwork, and the Director of Nursing confirmed that there was no hospitalization paperwork from the facility to the hospital for this incident. These findings were based on policy review, record review, and staff interviews.