Failure to Document and Prepare Resident for Safe Transfer/Discharge
Penalty
Summary
Facility staff failed to provide and document adequate preparation and orientation for a resident prior to transfer or discharge to a higher level of care. The clinical record lacked sufficient documentation to demonstrate that the resident was properly prepared or oriented for the transfer, as required by facility policy. The only progress note available for the transfer was brief and did not include necessary details about the preparation or orientation provided to the resident. The resident involved had multiple significant diagnoses, including heart failure, chronic respiratory failure, atrial fibrillation, and anxiety disorder, and was assessed as moderately cognitively impaired. The DON confirmed that the family requested the transfer due to increased confusion, but acknowledged that the nurse responsible did not accurately document the discharge process. Facility policy requires thorough documentation of all services, changes in condition, and communication with family or other staff, which was not met in this instance.