Failure to Provide Required Documentation and Information During Resident Transfer
Penalty
Summary
The facility failed to provide required documentation and information to a resident or their responsible party prior to transferring the resident to the hospital. 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 necessary information were sent to the hospital at the time of transfer. Additionally, there was no evidence that the resident or their responsible party received education or review of the specific information required to be sent to the receiving facility. The resident's belongings were also not sent with them, and no bed hold notice was provided. Interviews with facility staff, including the DON, hospital liaison, and medical director, revealed that the decision to transfer the resident was made by the DON due to behavioral concerns, but the resident had not been assessed by a facility physician or psychiatric services prior to transfer. Communication between facility staff and the hospital was limited to verbal notification, and the hospital social workers confirmed that no paperwork or belongings accompanied the resident. The medical director stated they had no input in the transfer decision.