Failure to Provide Required Transfer Information During Hospital Transfer
Penalty
Summary
Facility staff failed to provide the required minimum information to the receiving provider when a resident was transferred to the hospital. Medical record review showed that after a resident developed swelling, redness, and warmth in the left lower extremity, a physician ordered diagnostic tests, which later confirmed ankle fractures. The Change in Condition form, which includes a section for documenting specific information for hospital transfers, was left blank at the time of transfer. Nursing notes indicated that the resident was sent to the hospital following physician orders, but there was no documentation that the necessary transfer information was communicated to the receiving facility. Both the Administrator and DON confirmed during interviews that the required hospital transfer information was not documented or sent with the resident.