Failure to Communicate Essential Resident Information During Hospital Transfers
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to receiving health care providers during transfers for two residents. Facility policy on transfer and discharge, last reviewed on 11/1/25, required that residents or their representatives receive written notification of impending transfer or discharge and that specific information be conveyed to the receiving provider, including practitioner contact information, resident representative information, advance directives, special instructions or precautions for ongoing care, comprehensive care plan goals, and all other necessary information, including a copy of the discharge summary. The policy also required that the medical record contain the discharge summary information and identify the recipient of the summary. For one discharged resident (R1), admitted on an unspecified date with diagnoses including hypertension, anxiety, and chronic respiratory failure, the clinical record showed the resident was transferred to the hospital on 3/8/26 and did not return. There was no documented evidence that the facility communicated the resident’s care plan goals, advance directive information, specific instructions for ongoing care, resident representative information, or all information necessary to meet the resident’s specific needs to the receiving provider. For another resident (R3), admitted on an unspecified date with diagnoses of hypertension, diabetes, and hyperlipidemia, nursing notes documented an episode of unresponsiveness during lunch with abnormal vital signs, subsequent partial recovery, and a decision by the nurse practitioner to send the resident to the hospital with the niece’s agreement. Review of this resident’s record likewise revealed no documented evidence that the required information, including care plan goals, advance directives, instructions for ongoing care, resident representative information, and all necessary information, was communicated to the receiving provider. In an interview, the ADON confirmed the facility failed to ensure necessary information was communicated for these two residents.
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