Failure to Provide Required Transfer Documentation for Hospitalized Residents
Penalty
Summary
The facility failed to ensure that required transfer and resident clinical information was completed for two residents who were transferred to the hospital. For one resident with multiple diagnoses including heart failure, depression, arthritis, diabetes, and septicemia, the documentation lacked copies of the bed hold form, the resident's clinical status prior to transfer, the reason for transfer, and the most recent diagnostic and lab tests. Although some information such as a Notice of Transfer or Discharge form and medication lists were provided, there was no comprehensive transfer documentation or checklist available, and the Director of Nursing confirmed that she could not provide these documents. Similarly, for another resident with diagnoses including malnutrition, atrial valve disorder, cancer, and heart failure, the record did not contain the required transfer documentation. The facility was unable to provide the bed hold form, clinical status prior to transfer, reason for transfer, or recent diagnostic and lab results. The Director of Nursing indicated that only a list of medications, POA information, and a verbal report to the hospital were provided, and no transfer checklist or policy regarding discharge/transfers was available at the time of the survey.