Lack of Physician Documentation for Facility-Initiated Transfer
Penalty
Summary
The facility failed to ensure that the necessary resident information was documented by the physician to facilitate a facility-initiated transfer of a resident with dementia. The resident was admitted with a diagnosis of dementia and was later discharged to another skilled nursing facility because the facility determined it could not meet the resident's needs. Documentation from the Director of Nursing indicated that the resident exhibited behaviors such as attempting to elope, pulling fire alarms, threatening to let other residents out, inappropriate touching, entering other residents' rooms and taking items, and frequent falls despite interventions. Meetings were held with the resident's responsible party and the interdisciplinary team to discuss the need for transfer, and arrangements were made with the receiving facility, which had a secured unit. However, there was no evidence in the resident's clinical record of physician documentation prior to discharge that specified the necessity of the transfer for the resident's welfare, the specific needs that could not be met, the facility's attempts to meet those needs, or the services available at the receiving facility to address those needs. This lack of required physician documentation was confirmed during a telephone interview with the Nursing Home Administrator and Director of Nursing.