Failure to Complete and Send Required Transfer Documentation During Hospital Transfer
Penalty
Summary
The facility failed to ensure that a discharge summary and required transfer documentation were completed and sent with a resident who was transferred to the hospital via the emergency department. The resident in question required skilled level of care following a post colostomy placement due to bowel obstruction and had multiple surgical interventions, including a JP drain, midline abdominal incision with staples, and an ostomy. On the day of transfer, the resident developed a fever and increased purulent drainage from the abdominal incision, prompting evaluation at the nearest emergency department per physician order. Progress notes indicated that the resident was admitted to the hospital, started on IV antibiotics, and treated for pneumonia, with a bed hold requested by the resident's husband. The resident later returned to the facility after receiving additional treatments, including a blood transfusion. However, a review of the resident's progress notes and facility records did not reveal any documentation that transfer discharge paperwork or required information was sent with the resident to the hospital. Interviews with the Director of Nursing and Assistant Director of Nursing confirmed that there was no evidence that staff followed the facility's transfer discharge procedure, which includes sending specific documentation and providing notifications regarding bed hold policy. The facility's policy outlines the necessary steps and information to be provided during emergency transfers, but in this instance, the required documentation and notifications were not completed or sent.