Failure to Provide Required Transfer Reports to Receiving Hospitals
Penalty
Summary
The facility failed to provide required reports to the receiving healthcare institution following emergent transfers for two of four sampled residents. For one resident, who was alert, oriented, receiving dialysis, required extensive assistance with transfers, and had an active infectious disease requiring transmission-based precautions, the facility did not document or communicate the resident's care needs to the hospital after the resident and spouse requested hospital transfer due to body pain. The nurse responsible for the transfer confirmed that no report was given to the hospital. For another resident, who was rarely understood, required total assistance with all activities of daily living, and had a urinary catheter, the facility also failed to document or communicate the resident's care needs to the hospital after the resident was found unresponsive and sent to the hospital via 911. The Director of Nursing confirmed that staff are expected to call the hospital and provide a report, but this was not done in this case.