| 95 |
BRANDYWINE NURSING & REHABILITATION CENTER |
85004 |
505 GREENBANK ROAD |
WILMINGTON |
DE |
19808 |
2018-07-19 |
622 |
D |
1 |
0 |
B13F11 |
> Based on interview, record review and other documentation as indicated, it was determined that the facility failed to ensure that one (R1) out of 3 residents was transferred in a manner that provided an effective transition of care. R1 was transferred from facility (F#1) to another facility (F#2) on 6/29/18. F#1 failed to have a transfer/discharge policy, to provide report to F#2 on R1's status prior to transfer, there was no physician order to transfer R1, and there was a lack of evidence that all pertinent paperwork was sent to F#2. All references to C#'s are staff at the receiving facility (F#2). Findings include: Review of R1's clinical record revealed the following: R1 was admitted to F#1 on 5/24/18 for short-term rehabilitation following a hospitalization . Review of a progress note written by E6 (NP) on 6/25/18, stated, .Anticipatory discharge from rehab (rehabilitation) services 6/28/18 . Review of the progress notes, dated 6/29/18, the day R1 was transferred to F#2, lacked evidence of a nurse's note, including documentation of respiratory status and evidence that report was called to F#2. Review of physician orders revealed the lack of a physician order to transfer R1. 7/11/18 3:17 PM- E2 (DON) was asked for a copy of the transfer information provided to F#2. E2 stated there was no form, however, the nurse calls report and sends hardcopy papers over that the facility needs, like care plans, meds (medications), etc. E2 confirmed that a physician order was not written to transfer R1 and that a nurse's note should have been written, including what time R1 left. 7/12/18 12:39 PM- E4 (agency nurse, LPN) was assigned to R1 on 6/29/18. E4 was asked via telephone if he did R1's transfer and E4 stated, No, I've never discharged anyone. 7/12/18 approximately 12:50 PM- E3 (LPN/UM) was asked if she did R1's transfer on 6/29/18 and E3 stated that she did not. When asked what her expectations were when a resident was transferred, E3 stated, .to call report (to the receiving facility), and send copies of notes. 7/12/18 2:21 PM- E5 (SS) was asked if she sent any paperwork to F#2. E5 stated that she faxed a copy of the face sheet, medications, and progress notes about a week before R1 left; when a decision was made by C1 (ED) to accept R1. 7/12/18 4:20 PM- During an interview with E5, she provided a copy of R1's Medication Review Report (summary of physician's orders) that was faxed from F#2's medical records department on 7/12/18 at 3:11 PM per request by E5 (E5 had previously faxed the report to F#2 on a different date). This was the only evidence of paperwork sent from F#1 to F#2. 7/13/18 1:05 PM- E3 was asked what the 6/28/18 date and time meant on R1's Medication Review Report. E3 stated that it was the date and time she printed the document. E3 was unable to provide a fax confirmation of when the Medication Review Report was sent to F#2. 7/13/18 12:55 PM- E2 confirmed that the facility does not have a transfer policy. An investigator from the Division of Health Care Quality (state) did interviews of key staff at F#2, obtained written statements and supplied copies of email correspondence to the surveyor. Documentation from F#2 revealed: 7/13/18 10:47 AM- C4 (RN) stated during an interview that the only documentation that came from F#1 was on 6/28/18 (the Medication Review Report) and the family gave them some paperwork from F#1 that was unclear. An undated written statement by C4 stated that she attempted to call F#1 for report, that the fax number was given to the nurse and she stated that she will fax the report/paper work (sic) . called facility another time reminding them that I am still waiting for the paper work . we did not have any report . F#1 failed to have a transfer/discharge policy, provide report to F#2 on R1's status prior to transfer, failed to ensure a physician's order was written to transfer R1, and there was lack of evidence that all pertinent paperwork was sent to F#2 to ensure an effective transition of care. |
2020-09-01 |