Failure to Communicate Resident Needs Prior to Discharge
Penalty
Summary
The facility failed to arrange for a safe and orderly discharge for one resident when it did not communicate the resident's medical conditions and needs to the receiving Intermediate Care Facility (ICF) prior to transfer. The resident had significant medical diagnoses, including acute kidney failure, malignant melanoma, and dysphagia, and was severely impaired in cognitive skills, requiring substantial to maximal assistance with activities of daily living. Upon arrival at the ICF, staff determined that the resident had bed sores and an infected tumor on the neck, conditions that the ICF was not equipped to manage. The ICF administrator reported not receiving any transfer paperwork or communication regarding the resident's needs before the transfer and stated that the facility was not appropriate for the resident's level of care. The case manager responsible for the discharge confirmed that there was no evidence, such as a fax confirmation or phone call, to show that the resident's medical needs were communicated to the receiving ICF prior to discharge. The facility's policy required comprehensive information to be conveyed to the receiving provider at the time of transfer or discharge, including medical status, care needs, and special instructions, but this was not followed in this instance.