1. Murray, Elizabeth BSN, RN, LNCC

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From a legal standpoint, the top priorities for patient transfer from hospital care to long-term care (LTC) or a skilled nursing facility are avoiding readmission and decreasing complaints or liability concerns. A solid understanding of the standard of care for discharge documentation and the liability issues for older adult patients transferred to an LTC facility will ensure that nursing staff members have positive outcomes.

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Know the definitions

According to Legal Nurse Consulting Principles, 3rd Edition, "standard of care" is a term used to designate what's accepted as reasonable conduct under the circumstances by a person in the same profession.1 In a malpractice claim, the standard of care is defined as the "degree of skill, care, and judgment used by an ordinary, prudent healthcare provider under similar circumstances. The standard of care may recognize more than one reasonable action in a given situation."1


The Joint Commission has defined "transition of care" as the movement of a patient from one healthcare provider or setting to another.2 How transfers, or transitions of care, are handled by each facility can have a major impact on the vulnerable older adult patient population. The Joint Commission is at the tail end of a 3-year initiative to "define methods to achieve improvement in the effectiveness of the transitions of patients between healthcare organizations and provide for the continuation of safe, quality care for patients in all settings."2


In a published report on the initiative, The Joint Commission recommended identifying patient populations at high risk for readmission upon discharge. The factors included diagnoses associated with high readmissions; comorbidities; the need for numerous medications; a history of readmissions; psychosocial and emotional factors; the lack of a family member, friend, or other caregiver for support or assistance; older age; financial distress; and deficient living environment.2 Patients discharged to LTC or skilled nursing facilities can, and usually do, have all of the identified factors, which place them at high risk for complications and readmission.


Although the exact standard for each unit may vary slightly by state, there are many accepted requirements for transfer notes out of the hospital. Several studies have recommended the use of standardized transfer forms, and some states have adopted a standardized form to help hospitals exchange accurate information with the LTC facility to avoid further health complications and readmission.3 Having a standardized form can prompt nursing staff members to communicate important information; however, a crucial part of the handoff is thoughtful completion of the form to ensure that all prompts are addressed. It's critical that the form is filled out in its entirety to protect both facilities should the patient's care be challenged.


In my review of records of patient transfers from the hospital to LTC, many sections of standardized transfer forms are often left unaddressed. The discharging nurse may not feel that the information is useful, but in most cases all of the information on a standardized transfer form is helpful to the receiving facility and can answer questions in later review as to the patient's readiness for discharge.


Recognize "hot" areas

Although many LTC residents have serious chronic illnesses, the LTC facility is where they live and strive to maintain a normal day-to-day routine. LTC facilities strive to maintain residents' level of health and optimize their quality of life with care plans that address every facet of their mental and physical needs. These individuals tend to have five main areas of liability, or areas of complaint, after they arrive in LTC:


* falls


* skin issues


* infection


* nutrition/hydration


* change of condition monitoring.



When reviewing a standardized transfer form, ensure that these areas in particular are addressed. Communicate any skin alterations, whether due to pressure, moisture, or bruising/scratches from injections or treatments; vital signs upon discharge; and an accurate weight. These items may not seem important to a discharging nurse because the patient is now well enough to leave the hospital; however, if there's litigation surrounding a patient's care at a later time, this information can be valuable for protecting the facility from liability.


Take the necessary steps

In July 2014, the Institute for Safe Medication Practices (ISMP) published a helpful bulletin on protecting vulnerable patients during handoffs, specifically from the hospital to LTC.4 The ISMP reported that many medication errors made at LTC facilities after transfer from a hospital often originated in the hospital with unclear transfer documentation and instructions for the LTC facility. The ISMP identified the medications most often involved in errors during transition to a LTC facility, which include warfarin, insulin, opioids, and cardiovascular medications.4 This information can be used by nurse managers and discharge planners to identify patients who are at high risk for such errors during transfer.


Although the ISMP recommendations were created specifically to decrease medication errors, their implementation can ensure a more thoughtful discharge and transfer process, which improves patient handoff and increases the interdisciplinary team's input into discharge documentation. The ISMP made the following recommendations to consider for each patient upon transfer to LTC:


* establish a list of generic medication categories (such as pain medications, sleeping aids, and proton pump inhibitors) that are generally not continued after hospitalization and refer to the list during discharge medication reconciliation


* don't write "continue orders" on discharge summaries; there must be a new, complete order for each medication


* verify accuracy of discharge summaries and require prescribers to cosign the dictation and transcription of discharge summaries


* complete discharge summaries in a timely manner; a discharge summary signed 2 weeks after discharge doesn't help the LTC facility determine an accurate care plan for a patient upon transfer from the hospital


* provide reasons for changes; LTC facility's medication administration record (MAR) systems usually require a purpose for each medication to be listed with the order


* identify the drugs listed by the ISMP as likely to be involved in transitional medication errors (such as warfarin, insulin, opioids, and cardiovascular medications) and ensure that the orders for discharge routes and dosages are clear and accurate


* involve the pharmacy in documentation of the transfer process by instituting a sign-off by pharmacy staff during the discharge instructions and medication reconciliation process


* provide information early; when possible, send the transfer information a few hours ahead of the patient and verbally confirm the information with the receiving nurse


* solicit feedback from the LTC facility and ask them to report any discrepancies in the orders, forms, or MAR so that transitions can be continually improved.4



Ensure safe transitions

Transitions from the hospital to LTC can be a time fraught with potential liability for both the discharging hospital and the receiving LTC facility. Even more important than liability, discharging nurses are concerned with the safety of vulnerable older adult patients in transition. There are many concrete steps that a unit can take to address the particular issues surrounding most LTC patients and improve the measureable outcomes of reducing readmissions and decreasing complaints.




1. Peterson AM, Kopishke L. Legal Nurse Consulting Principles. 3rd ed. Boca Raton, FL: CRC Press; 2010:2-11. [Context Link]


2. The Joint Commission. Transitions in care: the need for a more effective approach to continuing patient care. [Context Link]


3. Oregon Patient Safety Commission. Care transitions: strengthening communication, improving outcomes. [Context Link]


4. Institute for Safe Medication Practices. From the hospital to long-term care: protecting vulnerable patients during handoffs. [Context Link]