Failure to Document and Communicate Required Information During Resident Transfers
Penalty
Summary
The facility failed to ensure that the transfer or discharge of two residents was properly documented in their medical records, and that all required information was communicated to the receiving provider. For both residents, there was no documentation of a transfer or discharge summary, nor was there evidence of what information was sent to the receiving provider at the time of transfer. This included missing details such as contact information for the practitioner responsible for the resident's care, resident representative contact information, advanced directive information, special instructions or precautions for ongoing care, comprehensive care plan goals, and other necessary information to ensure a safe and effective transition. One resident with diagnoses including HIV, anxiety disorder, schizophrenia, and hepatitis C was transferred to a hospital after calling 911 due to complaints of brain pain, but the medical record lacked documentation of what information was provided to the hospital. Another resident with multiple complex conditions, including diabetes, chronic kidney disease, traumatic amputation, bipolar disorder, and suicidal ideations, was transferred to the hospital on two occasions due to acute medical changes, but again, the medical record did not contain documentation of a transfer/discharge summary or what information was sent to the receiving provider. Interviews with staff confirmed that while there was a process for notifying providers and sending documentation, it was not consistently documented in the residents' records.