Failure to Document Transmission of Pertinent Health Information During Hospital Transfers
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pertinent health information, including care plan goals and advance directive information, was provided to receiving hospitals when residents were transferred. Policy review showed that the facility’s “Discharge or Transfer” policy, revised on 8/30/25, required that information conveyed to receiving providers for residents being transferred or discharged be provided in accordance with federal guidance. Despite this policy, surveyors found multiple instances where the medical records did not contain documentation that the required information was sent with the residents at the time of transfer. For one resident with progressive supranuclear ophthalmoplegia and a history of pulmonary embolism, eINTERACT Transfer Forms documented several discharges to the hospital for head pain and falls on multiple dates. However, for each of these transfers, the resident’s medical record lacked documentation that care plan goals and advance directive information were provided to the hospital. Another resident with Parkinson’s disease and chronic kidney disease was transferred to the hospital for lacerations on two separate occasions, and in both cases, the medical record did not show that the required pertinent medical information, including care plan goals and advance directives, was sent to the receiving facility. Additional residents with diagnoses such as bipolar disorder, anxiety, COPD, obstructive sleep apnea, heart failure, and COPD were also transferred to the hospital on multiple occasions for issues including shortness of breath, pain, diarrhea, elevated heart rate, altered mental status, chest pain, and other conditions. For each of these transfers, the medical records similarly lacked documentation that care plan goals and advance directive information were provided to the receiving hospitals. During an interview, the CNO stated that nurses had completed the eINTERACT charting in Point Click Care but had not documented which forms were sent to the hospital, acknowledging that this documentation should have been completed.
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