Failure to Communicate Required Resident Information During Hospital Transfers
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider during hospital transfers for two residents. According to the facility's own policy, information such as the provider's contact details, resident representative or POA contact, advanced directives, special care instructions, care plan goals, and other relevant information must be provided to ensure a safe and effective transition. However, clinical record reviews for two residents who were transferred to the hospital and later returned showed no documented evidence that this required information was communicated to the receiving provider. One resident had diagnoses including lung cancer, stroke, and anemia, while another had a left femur fracture, dysphagia, and muscle weakness. In both cases, the clinical records did not contain documentation of communicated care plan goals, advanced directive information, specific instructions for ongoing care, or resident representative information at the time of transfer. The DON confirmed during interviews that the necessary information was not communicated for these residents, as required by facility policy and regulatory standards.