Failure to Document and Communicate Resident Transfer to Hospital
Penalty
Summary
The facility failed to properly document the transfer process and communication to the receiving health care facility for one resident who was hospitalized. The resident, who had diagnoses including pneumonia, chronic respiratory failure with hypoxia, COPD, and congestive heart failure, was noted to be agitated, restless, and experiencing respiratory distress. After the family requested a transfer to the emergency room, emergency transport was arranged, but the clinical record did not show that the receiving facility was notified of the transfer, nor did it include documentation of the resident's condition at the time of transfer or a completed transfer form. Interviews with the DON and an RN confirmed that required documentation, such as the SBAR communication form and Interact transfer form, was not completed. The facility's policy required these forms to be filled out and the receiving facility to be notified during a transfer. The resident's record lacked evidence that these procedures were followed, and the necessary transfer documentation was missing from the medical record.