Failure to Provide Required Transfer Documentation to Receiving Facility
Penalty
Summary
The facility failed to provide federally required transfer documentation to the receiving health care institution for two of three sampled residents. According to the facility's own policy, when a resident is transferred to another provider, specific information must be sent, including practitioner contact information, resident representative details, advance directives, current status, diagnoses, medications, recent labs, special instructions, and the resident's care plan goals. For both residents in question, record reviews showed that after each sustained a fall and was transferred to the hospital for evaluation and treatment, there was no evidence in the electronic health record or scanned documents that the required transfer information was sent to the hospital. Interviews with the facility Administrator confirmed that the necessary documentation was not provided at the time of transfer for either resident. The deficiency was identified through review of progress notes, assessments, and other records, which lacked the federally mandated information transfer. The facility's failure to send this information was acknowledged by the Administrator during the surveyor's interview.