Failure to Document Resident Status and Reason for Hospital Transfer
Penalty
Summary
A deficiency was identified when a resident was transferred or discharged to an acute care hospital, and the facility failed to document the resident's status at the time of discharge and the reason for the transfer in the medical record. Medical record review showed a Transfer/Discharge Report with admission and discharge dates, but lacked information regarding the resident's condition or the rationale for the transfer. Staff interviews confirmed that standard procedure involves completing an EInteract Change in Condition form, notifying the physician, and documenting all actions in the progress notes, but in this case, there was no documentation or physician order related to the resident's change in condition that led to the hospital transfer. The Director of Nursing verified the absence of required documentation and physician order for the event.