Failure to Communicate Pertinent Information During Resident Transfer
Penalty
Summary
The facility failed to ensure that appropriate and pertinent information was communicated to the receiving health care institution during the transfer of a resident. Medical record review showed that a resident with multiple complex diagnoses, including arthritis due to bacteria, chronic pain, acute kidney failure, low back pain, hypo-osmolality and hyponatremia, multiple myeloma, hypertension, pneumonia, ileus, and muscle weakness, was admitted and subsequently had laboratory orders to monitor hemoglobin levels. The resident's hemoglobin was found to be low, prompting a transfer to the hospital. Despite the transfer, the facility did not document that the resident was transported with the necessary information provided to the receiving facility. This was confirmed during an interview with the DON, who acknowledged the failure to ensure proper communication of the resident's clinical information at the time of transfer. Review of facility policy indicated that a standard tool should be used for early recognition and management of acute changes, including communication of situation, background, and assessment, but this protocol was not followed in this instance.