Failure to Document and Notify Required Information During Resident Hospital Transfers
Penalty
Summary
The facility failed to complete required documentation and notifications related to resident hospital transfers for three of four sampled residents. Specifically, the facility did not document the basis for hospital transfers, the specific resident needs that could not be met, the facility's attempts to meet those needs, or the services available at the receiving facility. Additionally, there was no documentation of what information was communicated to the receiving provider, nor evidence that a bed hold was offered to residents upon transfer, as required by policy. For one resident with medically complex conditions and moderate cognitive impairment, there were three hospital transfers for wound assessment, a hand injury, and abdominal pain, but no documentation was found regarding information provided to the hospital or bed hold offers for two of the transfers. Another resident, cognitively intact and admitted with fractures, was transferred to the hospital four times for pain management, a fall, blood-tinged urine, and bladder pain, with no documentation of information communicated to the receiving facility. A third resident, also admitted with fractures, was transferred to the hospital for chest pain shortly after admission, again with no documentation of information provided to the hospital or a bed hold offer. Interviews with staff revealed a lack of awareness and adherence to documentation requirements, including notification to the Office of the State LTC Ombudsman for transfers and discharges. Staff acknowledged that documentation was often incomplete or missing, and that the Ombudsman was only notified in cases of discharge against medical advice, not for all required transfers or discharges.