Transfer of Resident to Acute Care Approved by: Senior Operating Officer, Mental Health & Seniors Care Edmonton; and Senior Operating Officer, Rural Services Applicability: Continuing Care Corporate Policy & Procedures Manual Number: VII-C-85 Date Approved May 8, 2018 Date Effective Next Review (3 years from Effective Date) June 2021 NOTE: The first appearance of terms in bold in the body of this document (except titles) are defined terms please refer to the Definitions section. Purpose To provide guidance to staff regarding the effective and consistent process for transferring of resident information when a resident has to transfer to an alternative level of care/acute care. Principles The resident shall be considered for transfer to an alternative level of care when: the resident requires additional health services that are not available at the site emergency medical services are requested by the attending physician or the charge nurse unforeseen circumstances affect the environment, i.e. when it is considered not safe for the resident to remain in his/her current location. the resident/legal representative/family requests it. (Costs for transportation related to this would be the resident s responsibility.) Effective communication is a critical element in improving resident safety and includes transfer of information at transition times: within the organization: a. between staff, b. with the resident, c. with the resident s legal representative/family, d. with the most responsible health practitioner. and outside the organization: a. with primary healthcare providers, b. with the receiving site. Procedure 1. Complete the Patient Transfer Information Form (link)/site specific Transfer form and forward to the receiving site. Keep a hard copy of the Transfer Form in the resident's health record. 2. Ensure the following documents accompany the resident to the receiving facility: 2.1 copy of the Personal Directives(if completed); 2.2 Declaration of Incapacity (if present); 2.3 Green Sleeve with the signed: Goals of Care Designation Order(keep a copy); 2.4 copy of the current Medication Administration Record (MAR);
VII-C-85 Page 2 of 5 2.5 any relevant laboratory reports (eg. blood work) or diagnostic reports; 2.6 any records that would be considered part of the medication reconciliation process (which may include the admission best possible medication history, transfer or discharge medication reconciliation documents). 2.7 any other relevant information which could include: a. Diagnosis/ Face sheet b. Progress Notes (7 days) c. Vital Signs d. Allergies e. AROs f. Falls Assessment g. the Kardex (HCA Daily Plan of care), or Living Option Summary and Care Plan to ensure communication of resident specific care needs. 3. Communication with the Legal Representative/family 3.1 The designated health care professional shall contact the resident s legal representative/family regarding the transfer. Voice-to-voice contact should occur, ensuring that the legal representative/family is aware of the transfer. If the legal representative/family is not immediately available, a message to contact the site/health care professional may be left on voice mail. Ongoing calls must continue at a frequency appropriate to the urgency and the time of day, until direct contact is made. 3.2 Document each attempt to contact the legal representative/family in the progress notes. 3.3 Document the actual conversation with the legal representative/family once voice to voice contact has been made. Ensure that the legal representative/family is aware that the transfer is taking place and provide as much information about the transfer process as possible (eg. when, where, how, etc.) 3.4 Pre-arranged transfers may be communicated to legal representative/ family by the unit clerk or health care professional or their designate. 4. Communication with the Inter Disciplinary Team 4.1 Notify the responsible physician of the transfer as per site process 4.2 Communicate with the transfer team and/or the receiving site. Ensure the transfer team is aware of any special needs, equipment and/or Additional Precautions for Infection Control. 4.3 Inform pharmacy provider of any resident admissions to acute care within 24 hours. Follow site process for handling resident s medications e.g. return to pharmacy on next scheduled return etc.
VII-C-85 Page 3 of 5 4.4 For Supportive Living facilities/day Programs, notify the Alberta Health Services (AHS) Case Manager at Homecare. 4.5 Inform Nutrition/Food Services if special diet is provided. 4.6 Inform other disciplines as appropriate and as per site process. 4.7 Adhere to practices that protect the privacy of the resident s information (link to Information and Privacy Resources page on compassionnet: http://www.compassionnet.ca/page552.aspx ) 5. Documentation on Transfer 5.1 Complete all documentation on progress notes, including any messages for, or any conversations with contact person, the condition of resident at the time of transfer and mode of transportation (eg. ambulance, driven by family, etc.) Ensure documentation of the list of documents sent with the person. 5.2 Document resident s Admission Discharge Transfer status in the appropriate electronic health records (Long Term Care). 5.3 In Supportive Living: the notification of AHS Home Care Case Manager. 6. Further Documentation Process in Long Term Care if a resident is ADMITTED to Acute Care: 6.1 Enter the information on the resident s health record as being on medical leave. 6.2 While the resident is admitted to acute care, his/her continuing care bed is indicated as "BED ON HOLD" on the Daily Census Report for each day that the resident is absent. 6.3 Residents are allowed a maximum 50 consecutive days per year for hospital leave. On or before the 50 th day of the resident's transfer, the Unit Manager contacts the acute care unit to inquire about the resident's status. 6.3.1 If the resident is ready to return on or around the 50 th day, or there is reasonable expectation that the resident will return soon, the bed is held. 6.3.2 An expected date of return (readmission) is noted on the Daily Census Report. For Day Program: the Day of Return (readmission) is noted on the Daily census report. 6.4 If the resident is not ready to return by the fiftieth day and his/her condition warrants that he/she be hospitalized for a longer undefined time period, the
VII-C-85 Page 4 of 5 resident is discharged from the Continuing Care Program in consultation with the Program Manager or person responsible. This information is entered into the (electronic) health record as a discharge. 6.5 In Long Term Care, on return from leave (in acute care): 6.5.1 The resident must have new medication orders. 6.5.2 A new census: status: active, related action transfer in shall be completed under the resident s name in the (electronic) health record. 6.5.3 RAI/MDS 7 day tracking must be initiated if: 1) a significant change has occurred and/or, 2) a RAI- MDS assessment was missed, as per current guidelines for RAI assessments. 7.0 Day Program: If client is hospitalized and unable to attend, discharge from program after 14 days. When able to return, client is treated as an urgent re-admission. 7.1 The client s eligibility for re/new-admission will be determined on an individual basis. 8.0 Hospice: If a hospice resident is admitted to acute care they are discharged from the hospice program Definitions Best possible medication history means a complete and up-to-date list of the patient s current medications at the time of admission including: a) name of the medication (all prescribed, over-the-counter, herbal, vitamin, homeopathic, health remedies and substances of abuse), b) dosage, c) route of administration, d) frequency of administration, and e) time of last dose (as appropriate). Family means one or more individuals identified by the patient as an important support, and who the patient wishes to be included in any encounters with the health care system, including, but not limited to, family members, legal guardians, friends and informal caregivers. Health record means Covenant Health s legal record of the patient's diagnostic, treatment and care information. Health services means a service or actions performed for or with a patient to protect, promote or maintain health; to prevent illness; to diagnose, treat or rehabilitate; or to take care of the health needs of the ill, disabled, injured or dying. (Health Information Act [Alberta])
VII-C-85 Page 5 of 5 Legal Representative means a person who is authorized to make decisions with or on behalf of the patient. These may include specific decision-maker, a minor s legal representative, a guardian, a nearest relative in accordance with the Mental Health Act, an agent in accordance with a Personal Directive, or a person designated in accordance with the Human Tissue and Organ Donation Act. Related Documents Move-Out / Transfer Checklist Covenant Health Policies: VII-B-255 : Transfer of Patient/Resident Information and Accountability VII-B-235, Medication Reconciliation at Key Transitions of Care Information and Privacy Overview resources page on compassionnet: http://www.compassionnet.ca/page552.aspx Infection Prevention and Control: Additional Precautions http://www.compassionnet.ca/page2615.aspx References Freedom of Information and Protection of Privacy Act (Alberta) Personal Information Protection Act and the Health Information Act. Revision Date(s) August 18, 2017