Failure to Communicate Resident Information During Transfers and Obtain Physician Discharge Order
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider during hospital transfers for three residents. Specifically, for these residents, the clinical records did not contain documented evidence that their care plans or care plan goals were provided to the hospital at the time of transfer. This lack of communication included residents with significant medical histories such as acute pancreatitis, diabetes mellitus, hypertension, dysphagia, cancer, and heart failure. The absence of this documentation was confirmed through review of facility policy, clinical records, and staff interviews. Additionally, the facility failed to obtain a written physician order for the discharge of one resident who was sent home. The clinical record for this resident, who had diagnoses including high blood pressure, diabetes, and depression, did not include the required physician order for discharge. The Nursing Home Administrator confirmed both the lack of communication of resident information during hospital transfers and the missing physician order for discharge.