Failure to Send Required Transfer Documentation With Resident to Appointment
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to follow its own discharge/transfer guidelines when sending a resident out for an appointment. On 2/10/26, the resident was transported to an appointment without a face sheet, physician order sheet, or medication administration record, as reported by the receiving RN. The facility’s written policy, “Guidelines for discharge and transfer,” requires that for transfers to a higher level of care or hospital, staff complete the EHR discharge/transfer form and send the face sheet, advance directives, MAR/TAR, and other pertinent information. The DON stated that staff are aware of residents’ appointments the day prior and are expected to have the required paperwork ready and provided to the transporter at pickup. However, the resident’s night nurse reported she was not aware the resident had an appointment and therefore did not send the required documents. She further stated she had printed the face sheet and physician order sheet but did not send them because she could not access the computer room to retrieve them. As a result, the resident arrived at the appointment location without the documentation required by facility policy.
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