Failure to Complete Required Transfer Forms and Bed Hold Notices
Penalty
Summary
Facility staff failed to ensure that required electronic transfer forms and bed hold notices were completed in the electronic medical record system (Point Click Care) for a resident who was transferred to the hospital. During a review of the resident's medical record, it was found that while an electronic transfer form and bed hold notice were completed for one hospital transfer, there was no documentation of these forms for a subsequent transfer. The surveyor requested proof of the required documentation for the second transfer, but none was provided. Interviews with the DON and Regional Policy Nurse confirmed that the nurse responsible for the resident's care during the second hospital transfer did not complete the electronic interact transfer form or the bed hold notice as required. The DON explained that the process is typically completed at the time of transfer and is the responsibility of the nurse sending the resident to the hospital, regardless of the day or time the transfer occurs.