Failure to Timely Transfer Resident to Hospital After Provider Order
Penalty
Summary
The deficiency involves the facility’s failure to provide timely hospital transfer for a resident after a provider ordered the transfer based on recent lab results. Record review showed that the resident was admitted on an unspecified date and later sent to the hospital on another unspecified date. A 5‑day follow‑up report documented that at approximately 11:00 p.m. on 01/14/26, the resident’s provider ordered that the resident be sent to the hospital due to recent lab findings. However, the resident was not actually sent out until after 6:30 a.m. on 01/15/26. During this period, the RN on duty did not carry out the transfer order, stating that she did not send the resident because she was unable to print the documents needed for transfer to the hospital. Further interviews and record reviews clarified the circumstances around this delay. An LPN working the same night shift reported that the printer had not been working for a while at the beginning of the year and stated that he did not receive any education or disciplinary action related to transferring residents to the hospital. The Unit Manager confirmed that when she arrived at the facility on the morning of 01/15/26, the resident had still not been sent to the hospital despite the provider’s order from the previous night, and that the resident was then sent to the hospital at that time. The Unit Manager also stated that education and disciplinary action regarding sending residents to the hospital had been given verbally to the RN and LPN, but later confirmed, after reviewing their personnel files, that no disciplinary action had actually been documented for either staff member.
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