Improper Handling of Interfacility Admission and Same-Day Return Without Assessment or Documentation
Penalty
Summary
Facility 2 failed to ensure that a transfer/discharge met a resident’s needs and preferences and that the resident was prepared for a safe transfer/discharge. A resident with multiple diagnoses, including dementia and altered mental status, was discharged from an acute care facility (Facility 1) to Facility 2 with an approved admission and insurance authorization. Text messages and an email showed Facility 2 staff were notified in advance of the expected admission time, and an interfacility transport document, signed by the Assistant Director of Nursing, confirmed the resident’s arrival at Facility 2. Despite this, the Director of Nursing stated that when the resident arrived, staff determined the resident was not an appropriate fit for Facility 2. Facility 2 did not create a medical record for the resident, did not perform a nursing assessment, and did not initiate clinical care such as taking and recording vital signs as required by its admission policy. The resident was offered food and then sent back to Facility 1 the same day, without being properly admitted or discharged from Facility 2 and without documentation of why the resident was deemed inappropriate for the facility. Facility 2 also failed to provide required transfer/discharge documentation, including the reason for transfer/discharge, the effective date, the receiving location, and the resident’s appeal rights, and failed to appropriately communicate information about the resident’s condition to Facility 1 prior to returning the resident. Records from Facility 1 showed the resident returned there approximately seven hours after the initial discharge.
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