Failure to Communicate Required Resident Information During Facility-Initiated Transfer
Penalty
Summary
The facility failed to ensure that all necessary resident information was communicated to the receiving health care provider during a facility-initiated transfer for one of two sampled residents. According to the facility's policy, when a resident is transferred or discharged, the transfer or discharge must be documented in the medical record, and appropriate information—including practitioner contact information, resident representative details, advance directive information, instructions for ongoing care, care plan goals, and a discharge summary—must be provided to the receiving provider. However, a review of the clinical record for a resident with diagnoses including anemia, adult failure to thrive, and malnutrition, who was transferred to the hospital after complaining of chest pain and right-sided weakness, revealed no documented evidence that this required information was communicated to the receiving health care provider. Staff interviews and record reviews confirmed that the necessary documentation and communication were not completed for the resident transferred and expected to return. Specifically, there was no evidence that the resident's care plan goals, advanced directive information, specific instructions for ongoing care, and all other necessary information were provided to ensure effective transitional care, as required by facility policy and regulatory standards.