Failure to Provide Accurate Resident Identification During Emergency Transfer
Penalty
Summary
The facility failed to ensure accurate and appropriate information was communicated to the receiving health care provider during an emergent discharge. When a resident experienced a significant change in condition requiring emergency transfer to an acute care facility, an LPN incorrectly identified the resident and sent the individual to the hospital with another resident's identifiers and medical record. As a result, the resident was registered at the hospital under the wrong name and date of birth, and medical care was provided under the incorrect identity for approximately two hours. The error was discovered when the hospital contacted the facility to clarify the resident's identity. Record review showed that the resident who was actually transferred had a history of chronic obstructive pulmonary disease and congestive heart failure and was in severe respiratory distress at the time of transfer, requiring intubation. The incorrect medical record and identifiers were provided to EMS, and the resident was unable to correct the information due to decreased consciousness. The Director of Nursing Services confirmed that the wrong medical record was sent and acknowledged the resident's history of respiratory compromise. The incident resulted in the resident's representative not being contacted for consent for intubation, as the hospital had contacted the wrong representative based on the incorrect identifiers.