Resident Transferred in Error Without Discharge Order
Penalty
Summary
A deficiency occurred when a male resident with diagnoses including hypertension, dementia, anxiety, heart disease, and chronic kidney disease was admitted for hospice respite care. The resident's physician orders did not include any active discharge orders, and the care plan indicated a pre-discharge plan was to be established with family. Despite this, the resident was mistakenly transferred by ambulance after a report was given by an LVN, who later realized the wrong resident had been taken. The error was identified when the LVN went to the resident's room and found he was missing. Upon discovery, the resident was returned to the facility by ambulance within approximately 30 to 35 minutes. The LVN assessed the resident upon return and noted no apparent injuries or bruises. The incident was confirmed by interviews with the administrator and a hospice nurse, both of whom acknowledged that the resident was transferred in error and subsequently returned. The facility's policy states that residents are not to be transferred or discharged unless necessary for their welfare, but this policy was not followed in this instance.