Missing Required Transfer Documentation for Acutely Ill Resident
Penalty
Summary
The facility failed to ensure that required transfer and discharge documentation was included in a resident’s medical record to support communication of essential information to the receiving healthcare provider. A resident admitted with acute respiratory failure, pneumonia, and COPD had a care plan initiated that identified altered respiratory status and directed staff to monitor and report signs of compromised airway. A progress note later documented that the resident was not responding to an albuterol breathing treatment and had declining oxygen saturation requiring a higher level of care, and a Notice of Transfer or Discharge and a bed-hold agreement were completed for an immediate transfer due to urgent medical needs. However, the resident’s record did not contain documentation that the following required information was sent to the receiving provider at the time of transfer: contact information for the practitioner responsible for the resident’s care, resident representative contact information, advance directive information, all special instructions or precautions for ongoing care as appropriate, and comprehensive care plan goals. On review, the DON and CRN confirmed that the required transfer and discharge documentation was missing from the resident’s record.
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