Failure to Communicate Required Resident Information During Hospital Transfer
Penalty
Summary
The facility failed to ensure that all necessary resident information was communicated to the receiving health care provider during a transfer for one of three residents reviewed. Specifically, the facility's policy required that, for any transfer to another provider, information such as the resident's care plan goals, advanced directive information, specific instructions for ongoing care, and all information necessary to meet the resident's specific needs be provided to the receiving provider. However, a review of the clinical record for a resident who was transferred to a local hospital for a gastrostomy tube replacement revealed no documented evidence that this information was communicated in writing to the receiving health care provider. The resident involved had a medical history including stroke, diabetes, and high blood pressure, and was dependent on a feeding tube for the majority of caloric and fluid intake. Despite these complex care needs, the facility did not provide the required written information to the hospital at the time of transfer. This deficiency was confirmed by the DON during an interview, who acknowledged the failure to communicate the necessary resident information as outlined in facility policy.