Failure to Communicate Required Resident Information During Transfers
Penalty
Summary
The facility failed to ensure that all necessary resident information was communicated to the receiving health care provider during facility-initiated transfers for two residents. According to facility policy, a transfer form should be prepared and sent with the resident during an emergency transfer or discharge. However, a review of the clinical records for two residents who were transferred to the hospital revealed that there was no documented evidence that specific information, such as care plan goals, advanced directive information, instructions for ongoing care, resident representative information, and other details necessary to meet the residents' needs, was communicated to the receiving provider. One resident had a history of high blood pressure, diabetes, and dementia, while the other had muscle wasting, muscle weakness, dysphagia, and difficulty walking. Both residents were transferred to the hospital, and their records lacked the required documentation prior to transfer. This deficiency was confirmed during an interview with the Corporate Compliance Registered Nurse, who acknowledged that the necessary information was not present in the clinical records before the residents were transferred.