Failure to Send Required Resident Information During Hospital Transfers
Penalty
Summary
The facility failed to provide required documentation regarding resident health status to the hospital upon transfer for two of three residents reviewed for hospitalizations. For one resident with quadriplegia, kidney disease, and anemia, who was cognitively intact and dependent on staff for most activities of daily living, there was no evidence that any information was sent to the hospital when he was admitted due to a urinary tract infection. For another resident with Alzheimer's disease, kidney disease, anemia, depression, and high cholesterol, who was severely cognitively impaired and dependent on staff for care, there was also no documentation that information was sent to the hospital following a transfer after a fall resulting in a laceration. Interviews with facility staff, including an RN and the DON, confirmed that the process for hospital transfers should include sending a transfer form with resident demographics, physician's orders, and a list of medications. However, review of the records and facility policy revealed that this information was not sent for the two residents in question, despite the policy stating that such documentation should accompany residents for continuity of care during hospital transfers.