Failure to Provide Required Documentation During Resident Transfer
Penalty
Summary
The facility failed to provide the required documentation to the receiving facility during the transfer of a resident with multiple diagnoses, including dementia, borderline personality disorder, and a history of falls. The resident, who was on anticoagulant therapy and had documented cognitive impairment and behavioral symptoms, was transferred to the hospital after a family member noticed a bruise and called 911. Upon review, it was found that only a face sheet was provided to the paramedics, and the SNF/NF to Hospital Transfer Form lacked essential information such as relevant diagnoses, vital signs, and pain level. The document checklist on the transfer form was left blank, indicating that no additional documents accompanied the resident during the transfer. Interviews with facility staff revealed a lack of awareness regarding the required documentation for hospital transfers. The Executive Director was unfamiliar with the necessary documents, and the DON stated that only basic information was typically provided. Although a report was called into the hospital, there was no documentation of the specific information relayed. The facility's policy required that a face sheet, advance directives, current physician's orders, and pertinent labs or x-rays be attached during emergency transfers, but this was not followed in the resident's case.