Failure to Follow Discharge/Transfer Policy During Resident Hospitalization
Penalty
Summary
The facility failed to follow its own Discharge/Transfer policy for a resident who was hospitalized. According to the facility's policy, an SBAR (Situation Background Assessment Recommendation) assessment should be completed prior to contacting the provider, and a provider order should be obtained and entered into the electronic health record before transferring a resident to the emergency room or hospital. In this case, the resident, who had diagnoses including Paranoid Schizophrenia, Major Depression Disorder, and Hypertension, complained of multiple episodes of loose stool, nausea, and abdominal pain, and requested to be sent to the hospital. The DON was informed, and the resident was sent to the hospital via ambulance for further evaluation. Upon review, it was found that the required SBAR form was not completed prior to the transfer, and there was no documentation of a provider order authorizing the transfer. Interviews with facility staff confirmed that the SBAR was not completed and that there was uncertainty regarding the policy requirement for obtaining a physician's order before sending a resident to the emergency room. The facility was unable to provide any documentation regarding the transfer, indicating a failure to adhere to established procedures for resident transfers.