Failure to Document and Communicate Required Transfer Information
Penalty
Summary
A deficiency was identified when a resident with multiple complex medical conditions, including dementia with behavioral disturbances, diabetes, hypertension, and a history of repeated falls, was transferred from the facility to an acute care hospital. The resident, who had a severe cognitive deficit, was assessed by a nurse after becoming unresponsive to commands, and the transfer to the emergency room was initiated at the request of the resident's son. However, the medical record review revealed that there was no documentation of the disposition of the resident's transfer or the required information provided to the receiving provider. Specifically, the facility failed to document essential transfer information such as the physician responsible for the resident's care, resident representative information, advance directives, special instructions or precautions for ongoing care, comprehensive care plan goals, and other necessary details to ensure a safe and effective transition. The Director of Nursing confirmed that there was no evidence in the medical record that the receiving facility received the required information, and the transfer itself was not properly documented, which was not in accordance with the facility's own policy.