Failure to Clarify and Resume Pre-Hospital Interventions After Readmission
Penalty
Summary
The facility failed to notify the provider to clarify missing orders for previously established interventions after a resident returned from the hospital. Prior to hospital transfer, the resident had orders for an abduction pillow and a nutritional supplement, but these were not mentioned in the hospital's After Visit Summary upon readmission. The facility did not contact the provider to determine if these interventions should be resumed, resulting in the interventions not being reinstated. Interviews with the ADON, DON, and the Administrator confirmed that no clarification was sought regarding the continuation of these interventions, and there was no policy in place for reviewing or transcribing readmission orders to address such situations. The resident involved was admitted with multiple diagnoses, including malignant neoplasm of the cervix, protein-calorie malnutrition, vitamin D deficiency, and bilateral femoral neck fractures. The resident was cognitively impaired, with a BIMS score of 1, and was dependent for transfers and non-ambulatory. The lapse in continuity of care occurred because the facility did not verify whether to continue previously established interventions following the resident's return from the hospital.