F0658

D

Failure to Ensure Effective Nurse-to-Nurse Handoff Communication During Hospital Transfers

Elmwood Park, Illinois Survey Completed on 02-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure effective nurse-to-nurse communication and documentation during resident transfers to an acute care hospital, contrary to professional nursing standards and facility policy. For one resident with acute and chronic respiratory failure with hypoxia, ventilator dependence, anoxic brain damage, epilepsy, and a history of cardiac arrest, the record for a transfer for a GI bleed showed no documentation of a report being called to the hospital. The Hospital Transfer Form completed by the DON left blank the section for documenting to whom report was called, and the DON stated she did not call the hospital but only helped fill out forms. When requested, the facility could not provide any documentation or other evidence that a nurse-to-nurse report or verbal handoff occurred for that transfer.

For the same resident’s later transfer for tachycardia and seizure-like activity, the RN who initiated the transfer stated she believed she had called report to the receiving hospital but could not recall to whom she gave report, and there was no documentation in the medical record of a nurse-to-nurse report or verbal handoff. The RN documented notifying the family and giving information to paramedics, including face sheets and physician orders, but did not document communication with the hospital. The resident had a hospice consent signed several days prior to this transfer, but the SBAR form completed by the RN did not indicate that the resident was on hospice and did not document any communication to the hospital. The facility was unable to provide evidence that a verbal handoff or nurse-to-nurse report was completed at the time of this transfer.

A second resident with end stage renal disease, dialysis dependence, acute pulmonary edema, heart failure, hypoxemia, anemia in chronic kidney disease, type 2 diabetes, and peripheral vascular disease was transferred to the hospital on two occasions without documented nurse-to-nurse communication. For one transfer, the hospital transfer sheet completed by an RN did not document who received report at the hospital, and there were no nurse progress notes or other nursing documentation regarding handoff or hospital transfer. For a later transfer, initiated when the resident called 911 stating he did not feel well, the LPN documented that the resident was escorted to the emergency room and that a message was left for the next of kin, but the hospital transfer sheet did not document to whom report was called. The LPN stated she typically did not call the hospital when the resident self-initiated 911 calls, relied on paramedics and the hospital’s prior familiarity with the resident, and did not send physician orders in those situations. The DON described an expectation that nurses obtain physician orders, complete transfer and SBAR forms, notify family, call and give report to the hospital nurse, send a face sheet and physician orders, and document these actions in progress notes, which was not demonstrated in these cases.