Nursing Home to Nursing Home

Transfer of Care

NH Resident, Nursing Home staff at both facilities, Attending Physician at both facilities, Family Care Givers

Mrs. L was admitted to her first nursing home stay following an acute episode of CHF for short term rehabilitation. In addition to the acute exacerbation of her CHF, she has hypertension, chronic constipation, Vitamin B12 deficiency. She also admitted to some recent periods of confusion and daily forgetfulness, not being able to recall where she was going or what she had intended to get. On several occasions she had also found the range still on in the morning when she awoke, after having fixed dinner the previous evening. While at the nursing home, Mrs. L received physical and occupational therapy once each day to increase her strength and endurance. Early on in her stay the social worker visited Mrs. L to complete the Geriatric Depression Scale (GDS), a standard assessment for new admissions to the facility.

The GDS scored at a 9 indicating strong signs of depression.

Mrs. L was making steady progress with her therapy though she was by no means at a level to return to independent living. She still required transfer assistance and assistance with other ADLs such as bathing, toileting and dressing. During her four weeks at the nursing home her daughter was commuting 160 miles r/t twice a week to be with her mother and monitor her rehabilitation. While Mrs. L’s strength was increasing, her daughter was no longer feeling comfortable with her mother living alone due to her increasing confusion. With her daughter so far away and with young children at home who needed her care and attention as well, it was determined it would be better for mom to be closer to her daughter and a transfer was arranged to another nursing home closer to the daughter’s home.

Prior to transfer to the new nursing home Mrs. L’s MDS was updated to reflect her current level of care. She is now able to ambulate 125’ with stand by assist and a rolling walker, she is able to transfer herself from her wheelchair to bed with sit to stand assistance, she requires moderate assistance with bathing – getting into and out of the shower, supervision with toileting, moderate assistance with dressing and feeds herself with supervision/cueing.

Attending physician orders on transfer included an order to continue physical and occupational therapy at the new facility. A Continuity of Care Document (CCD) which included an updated MDS reflecting current ADL status, cognitive, mood and communication status, medication list, therapy notes, recent chest x-ray and labs was electronically forwarded to the new facility to ensure a successful transition of care for Mrs. L.

Upon admission to the new nursing home and with the information obtained from the CCD, the nursing staff and new physician were immediately able to put into place medical and restorative orders for continuing care. Physical and occupational therapy was begun the same day as admission with a plan to continue treatment as outlined by the prior facility. The nursing staff, including licensed nurses, nursing assistants and restorative staff were immediately aware of the assistance Mrs. L required with ambulation, bathing, toileting and dressing and a care plan was begun the day of admission to reflect these needs and the appropriate cues were posted on the bedside care plan. The Social Worker completed a new GDS assessment which reflected less signs of depression, scoring a 7 on this assessment. Mrs. L actually expressed relief at being closer to her daughter and not having to worry about daily chores such as grocery shopping and cooking on her own. She was also looking forward to visiting with her grandchildren more often and the Activity staff assisted her with putting together a collage of family pictures and showed her where games were kept that she might play during her grandchildren’s visits.

With the current and complete history available from the CCD, treatment was able to commence immediately upon admission, care plans were immediately put in place and the MDS staff had a complete history with which to begin their admission assessment. The daughter expressed gratitude to the staff at both facilities for such an easy transition of care.