Failure to Provide Resident-Specific Discharge Documentation During Hospital Transfer
Penalty
Summary
The facility failed to provide resident-specific discharge paperwork to the hospital during the transfer of a resident. Record review showed that the resident, who had multiple diagnoses including aftercare following a surgical procedure, was transported to an infectious disease clinic but refused to get out of the vehicle due to severe pain and diaphoresis. The clinic's physician assistant assessed the resident and sent him to the emergency room. However, the nursing notes did not document the reason for the resident's hospitalization, and there was no documentation in the record explaining why the resident was at the hospital. The Director of Nursing confirmed that the best practice would have been to document the resident's transfer and the reason for hospitalization, but this was not done.