Failure to Communicate Essential Information During Facility-Initiated Transfer
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider for a resident who experienced a facility-initiated transfer. Facility policy titled "Transfer and Discharge Notice" dated 2/2026 stated that the resident or representative would be notified prior to transfer or discharge and that documentation would be completed in the medical record. Resident R1 was admitted on an unspecified date and had an MDS dated 1/5/26 reflecting diagnoses of heart failure, Parkinson's disease, and hypertension. The resident was transferred to the hospital on 1/15/26 and did not return to the facility. Review of the resident’s clinical record showed no documented evidence that the facility communicated specific required information to the receiving provider for this transfer. Missing documentation included the resident’s care plan goals, advance directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident’s specific needs at the receiving facility. In an interview on 3/4/26 at 2:45 p.m., the DON confirmed that the facility failed to ensure that the necessary resident information was communicated to the receiving health care provider for this resident with a facility-initiated transfer, in violation of 28 Pa. Code: 201.29 (a)(c.3)(2) regarding resident rights.
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