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Based on interview and record review, the facility failed to communicate necessary patient care information to the receiving facility when Patient (Pt) A was transferred. The communication of specific continuing care needs assist the patient to adjust to his/her new living environment.

On September 19, 2005, a complaint was received by the Department that Pt A was discharged from the facility to a long term care facility without making the receiving facility aware that Pt A had two decubitus ulcers (bedsores).

On September 20, 2005 at 2:40 PM, the medical record for Pt A was reviewed. Pt A was admitted to the hospital after a fall on August 24, 2005 and was transferred to the long term care facility on September 7, 2005. Pt A's diagnoses were: "fracture of cervical spines 5,6," with a medical history of "mentally disabled". Pt A was 55 years old. On August 31, 2005, the first notation of a decubitus was documented in the Nurses' Notes. It read: "Skin breakdown coccyx (tailbone) Stage I-II." (Stage I represents intact skin with signs of impending ulceration. Stage II represents a partial-thickness loss of skin with extension into subcutaneous tissue.) On September 2, Nurses' Notes document a Stage II decubitus on the left elbow. On September 6, 2005, the Nurses' Notes read: "Has reddened areas on sides of feet." The Interfacility Transfer Report was provided by the Risk Manager (RM). This report was identified by the RM: "This goes with the patient to the new facility." On this transfer report, Pt A's pertinent mental and physical history were documented. Nursing care was specified in regard to transporting the patient, a cervical collar (neck support), the fact that Pt was non-verbal and specific nursing care the patient required for daily living. But no where on that transfer report sheet was the documentation of any
decubitus or the care that the transferring facility had been providing to attempt to heal them.

On June 23, 2010 at 4 PM, the facility's policy "Skilled Nursing Facility Transfer" was reviewed. It read: "A. General Information....3.... Providing each facility with all requested patient information, to obtain acceptance for continued care upon discharge of the patient, prior to actual discharge. No patient will be discharged from the hospital unless continuation of care plans have been established and placement has been obtained."