Deficiencies in Transition of Care Communication and Required Written Notifications
Penalty
Summary
The facility failed to ensure appropriate communication and documentation during resident transitions, resulting in deficiencies related to discharge planning and notification requirements. For one resident discharged to an assisted living facility (ALF), the care plan lacked documentation on facilitating the identification of an appropriate discharge location and assistance with obtaining necessary supplies and services. The Resident Assessment Tool (RAT) provided to the ALF contained inaccurate information regarding the resident's continence and psychosocial status, which did not align with the Minimum Data Set (MDS) and other clinical documentation. Additionally, there was no evidence that the facility processed orders for durable medical equipment or home health care as discussed in care plan meetings, and the discharge instructions form was incomplete regarding medical equipment arrangements. Further review revealed that although discharge orders for skilled nursing, physical and occupational therapy, and a home health aide were documented, there was no evidence that these orders or referrals were communicated to the receiving ALF. The facility also failed to document that discharge orders were sent to the ALF, and the Maryland Discharge Instructions form did not reflect the home health or therapy orders. Interviews with staff confirmed that some equipment orders were not placed as indicated, and home health services were not ordered because the ALF had its own therapy department, but this was not documented in the resident's record. In a separate incident, another resident was transferred to an acute care facility due to a change in condition. The resident's representative was notified by telephone, but there was no documentation that a written transfer notice or the facility's bed hold policy was provided as required. The admissions director stated that written notifications were only sent to short-stay residents' representatives, and the nursing home administrator confirmed that the facility had stopped mailing these documents to long-term care residents' representatives to avoid confusion. This resulted in a failure to provide required written notifications during the transfer process.