Failure to Document Transfer Information Sent to Hospital
Penalty
Summary
The facility failed to ensure proper documentation that required transfer information was provided to the receiving hospital for a resident who was transferred due to a fall, altered mental status, and elevated blood glucose level. Review of the resident's electronic medical records did not show any documentation regarding what information was sent to the hospital at the time of transfer. The only available document was an Acute Care Transfer Document Checklist, which included instructions for sending specific documents with the resident and required checkboxes to indicate which items were sent. However, none of the items on the checklist were checked to confirm that any information was actually sent with the resident. The checklist was signed by both the nurse and the ambulance staff, but there was no indication of which documents accompanied the resident. The Director of Nursing confirmed that this checklist was the only documentation available regarding the transfer, and no further information was provided during the survey process.