Failure to Notify Receiving Hospital of Resident Transfer
Penalty
Summary
A deficiency occurred when staff failed to notify the local emergency room hospital of a resident's transfer following an unwitnessed fall. The resident, who was found on the bedroom floor with a pillow under his head, was alert but only oriented to one sphere and unable to explain what happened. The nurse on duty prepared documents and gave a report to the oncoming nurse but did not notify the receiving hospital, citing uncertainty about the ambulance's arrival time. The oncoming nurse also did not notify the emergency room, stating that it was the ambulance driver's responsibility. Both the Director of Nursing and the Administrator stated that it is expected for nurses to notify the receiving facility of any transfer, especially for residents unable to advocate for themselves. The resident involved had a diagnosis of delirium due to a known physiological condition, cognitive function impairment, and abnormalities in gait and mobility, as documented in the admission record and care plan. Facility policy requires that the receiving facility be notified during emergency transfers or discharges. Despite this policy, the required notification was not made, resulting in a failure to communicate essential information about the resident's condition and transfer to the emergency room.