Failure to Document and Communicate Required Discharge and Transfer Information
Penalty
Summary
The facility failed to ensure that discharge information was sufficiently documented in the medical record for a resident who was transferred to the hospital. The medical record review revealed that the resident, who had complex medical conditions including pressure wounds, was admitted in February and transferred to the hospital in October after a request for hospital evaluation due to a worsening sacral wound. Documentation in the electronic medical record only noted the resident's request to go to the hospital and that the outgoing nurse sent the resident for wound evaluation, but did not include a comprehensive assessment prior to transfer, the reason for the transfer, or evidence that the physician was notified of the resident's request and status. Further review showed there was no documentation that appropriate and necessary information, such as a summary of the resident's status and the reason for transfer, was communicated to the receiving hospital. Additionally, there was no evidence that the resident or their representative was notified in writing of the transfer and the reasons for the move, nor was a written bed-hold notice specifying the duration of the bed-hold policy provided. The medical record also lacked a discharge summary completed by the resident's physician following the transfer and discharge from the facility.