Failure to Provide Required Transfer Documentation to Hospital
Penalty
Summary
The deficiency involves the facility’s failure to provide a transfer form to the hospital at the time of transfer for one resident. The resident was admitted with diagnoses including congestive heart failure, chronic kidney disease, and a history of urinary tract infections. The admission MDS showed a BIMS score of 10/15, indicating moderately impaired cognition. A plan of care note documented that the resident was found sitting in a chair with the light on and was not within normal limits for talking and walking ability, and that she had soiled herself in the chair. A family member was called and requested that the resident be taken to the emergency room for evaluation. The former DON stated that the night nurse alerted her that the resident was not doing well, and the resident was sent to the ER, where she was admitted with sepsis. The Interim DON reported being unable to find any evidence that a transfer notice was completed, despite stating that a transfer notice should have been done prior to going to the ER and should have included a nursing assessment, vital signs, and other pertinent information. Review of the facility’s “Charting and Documentation” policy indicated that all services provided, changes in condition, and events involving the resident must be documented in the medical record, and that documentation must be objective, complete, and accurate. The absence of a transfer notice for this resident at the time of hospital transfer constituted the cited deficiency.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.