Failure to Document and Communicate Resident Transfer to Hospital
Penalty
Summary
The facility failed to properly document the reason for transferring a resident to a local hospital and did not ensure appropriate communication with the receiving health facility. The clinical record for the resident, who had diagnoses including multiple sclerosis and hypertension, did not contain a physician's order for the hospital transfer, nor did it include a Situation, Background, Assessment, and Recommendation (SBAR) form to indicate the change in condition that prompted the transfer. Nursing notes indicated the resident was sent to the emergency room due to a decline in condition, but staff interviews revealed uncertainty about the specific reason for the transfer and a lack of documentation regarding what information was sent with the resident. The resident's care plan had been focused on discharge home with her spouse, and she had recently been referred to hospice services following a decline in her condition and the end of Medicare Part A coverage. Interviews with staff and the resident's family member revealed that discussions about an outstanding balance and the possibility of inpatient hospice occurred, but no formal 30-day discharge notice was issued. The family was informed that if payment was not received by midnight, the resident would be discharged to an inpatient hospice program, yet there was confusion among staff about the process and rationale for the late-night transfer to the hospital. Further, the receiving hospital contacted the facility to clarify the reason for the transfer, indicating a lack of clear communication. The facility's own policy required a physician's order for emergency transfers and documentation of assessment findings, which were not present in this case. The resident returned from the hospital without new orders, and staff interviews confirmed that standard procedures for documenting and communicating transfers were not followed.