Failure to Communicate Critical Clinical Information During Emergent Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that necessary resident-specific clinical information was communicated to the receiving health care provider during an emergent transfer. A resident, identified as Resident 51, was admitted to the facility on July 6, 2022, and had an advance directive indicating a no code status, meaning CPR was not to be initiated if the resident’s heart or breathing stopped. On April 6, 2026, at approximately 5:30 AM, the resident was accidentally administered another resident’s medication: morphine sulfate 0.5 ml. A progress note dated April 6, 2026, at 6:30 AM documented that Emergency Medical Services (EMS) were contacted and the resident was transferred to the emergency department for evaluation and treatment related to the medication error and accidental opioid exposure. However, review of the clinical record revealed no documented evidence that the facility communicated the details of this medication error to the receiving health care provider. Specifically, there was no documentation that the name of the medication, the dosage, the time it was administered, or the clinical circumstances surrounding the accidental administration were provided at the time of transfer. Further record review showed there was also no documented evidence that other essential information necessary for continuity of care was communicated to the receiving provider. This included the resident’s advance directive status, special instructions or precautions for ongoing care, baseline condition, or comprehensive care plan goals, as appropriate, to ensure a safe and effective transition of care. During an interview on April 9, 2026, the DON and NHA were unable to provide documentation that such necessary clinical information had been communicated at the time of the emergent transfer.
Plan Of Correction
1. Facility cannot retroactively correct deficiency as it relates to resident 51 on 4/6/2026. 2. Facility audit of last 10 resident transfers to hospital to ensure that e-interact UA (utilization assessment) and corresponding information on code status, MAR, face sheet and baseline condition were sent to hospital to ensure a safe and effective transition of care. 10/10 residents had corresponding documentation. 3. Licensed nursing staff educated on procedures for resident hospital transfers to include specific documentation to send with EMS to ensure an effective transition of care to include the PCC utilization assessment, baseline condition, code status, MAR, face sheet and reason for transfer. RN supervisor to verify proper information is collected and sent. 4. Audit of each hospital transfer will be completed by DON/designee X 2 months to ensure compliance with education. Results will be provided to the QA committee each month to verify compliance with regulatory requirements for hospital transfers. 5. April 25, 2026
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