Failure to Provide Required Transfer Documentation to Hospital
Penalty
Summary
The facility failed to ensure that required information was sent to the hospital when a resident was transferred. Medical record review showed that the resident was admitted to the facility and later transferred to the hospital, but there was no documentation indicating that the resident's care plan goals or other required information were sent with the resident. Interviews with facility staff, including the DON and hospital liaison, confirmed that the transfer occurred without the necessary paperwork or belongings being provided to the hospital. The hospital social workers also stated that they did not receive any paperwork or a bed hold notice for the resident upon transfer. Further review revealed that the facility's social worker was not involved in the discharge process and did not attempt to find alternative placement for the resident. The DON made the decision to send the resident back to the hospital due to behavioral concerns, but the resident had not been assessed by facility psychiatric services or a physician prior to transfer. The facility hospital liaison communicated with the hospital social worker about the transfer, but did not provide the required documentation. The medical director was not involved in the decision to transfer the resident.