Failure to Document and Notify on Resident Transfers and Discharges
Penalty
Summary
The facility failed to appropriately document and provide required transfer and discharge notices for two residents. For one resident with multiple complex diagnoses, including pneumonia, chronic respiratory failure, and cognitive communication deficit, the medical record showed that after a fall and head injury, the resident was sent to the hospital by emergency medical services. However, there was no transfer or discharge summary completed, and no transfer notice was provided in the medical record. The Director of Nursing confirmed the lack of documentation related to this discharge. For another resident with extensive medical conditions such as end stage renal disease, diabetes, and heart failure, the record indicated the resident experienced a significant drop in oxygen saturation and was sent to the hospital at the insistence of family and after physician notification. Despite this, the discharge summary in the medical record was left blank, and there was no evidence of a completed transfer notice. Facility policy requires that even in emergency transfers, documentation and notification must be completed as soon as practicable, but this was not done for these two residents.