Failure to Communicate Resident Information and Provide Bed-Hold Notification During Transfers
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider during facility-initiated transfers for two residents. Specifically, the clinical records for these residents did not contain documentation that care plan goals and all information necessary to meet the residents' specific needs were provided to the receiving facility at the time of transfer. Additionally, for one resident who was transferred to the hospital and later returned, there was no documented evidence that the resident or their representative was provided with written information about the facility's bed-hold policy at the time of transfer. Furthermore, the facility failed to obtain a physician discharge order for one resident who was discharged home. These deficiencies were confirmed through review of facility policy, clinical records, and staff interviews, which indicated that required notifications and documentation were not completed as per regulatory requirements. The residents involved had significant medical histories, including dementia, major depressive disorder, urinary tract infection, high blood pressure, anemia, and renal insufficiency.