Failure to Provide Required Documentation During Resident Transfers
Penalty
Summary
Facility staff failed to provide required documentation to the receiving hospital during facility-initiated transfers for two residents. In one case, a resident with moderate cognitive impairment, as indicated by a BIMS score of 8 out of 15, experienced respiratory distress on two separate occasions. On both occasions, the resident was transferred to the hospital after nursing staff administered treatments and notified the physician. However, there was no evidence in the electronic health record that the necessary documentation was sent to the hospital during these transfers. For another resident, staff did not provide evidence that clinical documentation necessary for continuity of care was sent to the hospital during a transfer for evaluation and treatment of high fever and subsequent admission for influenza, UTI, and sepsis. The clinical record lacked documentation that the resident's representative and physician contact information, advance directive information, instructions for ongoing care, medication list, or care plan goals were sent to the receiving facility. Interviews with administrative staff and nursing personnel confirmed that there was no evidence of the required documentation being sent during these transfers. The facility's policy stated that an approved transfer and referral record, along with any additional medical information required by the receiving facility, should accompany the resident during transfer, but this was not evidenced in the reviewed cases.