Failure to Provide Required Clinical Documentation and Communication During Resident Hospital Transfer
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including Type 2 Diabetes Mellitus, osteomyelitis of the left ankle and foot, and a diabetic ulcer, experienced a change in condition and was transferred to the hospital emergency department (ED). At the time of transfer, the facility failed to send essential clinical and medical documentation with the resident. The only documents provided were a face sheet and a medication list; critical items such as the Health Care Proxy Form, Massachusetts Medical Orders for Life Sustaining Treatment (MOLST), and a completed Hospital Transfer Form were not sent. Additionally, there was no nurse-to-nurse report provided to the ED at the time of transfer. Interviews with facility staff confirmed that the expected protocol was to send the face sheet, MOLST, Health Care Proxy Form, physician's orders, and a completed Hospital Transfer Form with the resident, and to provide a nurse-to-nurse report to the receiving hospital. However, the nurse responsible for the transfer was uncertain about which documents were sent and did not complete or send all required forms. The ED nurse had to contact the facility hours later to obtain additional clinical information, and a review of the electronic health record confirmed that the Hospital Transfer Form was not completed as required.