Failure to Communicate Resident Information and Document Transfer Reasons
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to receiving health care providers and did not document the reasons for transfers to alternate health care providers for seven residents who experienced facility-initiated transfers. Facility policy requires notification of the resident and, if known, their family or representative, as well as documentation of the reason for transfer in the clinical record. However, reviews of the clinical records for these residents showed no evidence that such notifications or documentation occurred. For each of the seven residents involved, the clinical records lacked documentation that specific information was communicated to the receiving health care provider. This information should have included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, and all necessary details to meet the resident's needs at the receiving facility. The records also failed to include the reasons for each resident's transfer. The residents affected had various diagnoses, including schizoaffective disorder, anxiety, insomnia, bipolar disorder, high blood pressure, dementia, Alzheimer's disease, anemia, hyperlipidemia, hypothyroidism, COPD, malnutrition, schizophrenia, low blood pressure, peripheral vascular disease, and chronic kidney disease. During an interview, the DON confirmed that the facility did not ensure the required communication and documentation for these transfers. The deficiency was identified through review of facility policy, clinical records, and staff interviews, and it was found to be in violation of 28 Pa. Code: 201.29 (a)(c.3)(2) regarding resident rights.