Failure to Communicate Clinical Information During Resident Transfers
Penalty
Summary
The facility failed to ensure that necessary clinical information was communicated to the receiving health care provider when three residents were transferred to the hospital. According to facility policy, clinical records describing the residents' needs, including a list of orders and medications as directed by the attending physician, should accompany the resident upon transfer. However, for three residents with complex medical histories—including conditions such as congestive heart failure, COPD, diabetes, hypertension, dementia, hypothyroidism, and dependence on renal dialysis—there was no evidence in their clinical records that this information was provided to the hospital at the time of transfer. Review of the clinical records for these residents showed documentation of their transfer to the hospital, but lacked any indication that their necessary clinical information was communicated to the receiving provider. The Director of Nursing confirmed during an interview that there was no evidence of this required communication for the affected residents and acknowledged that clinical information should have been provided at the time of transfer.