Health inspection·August 12, 2024

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. Based on interview, and record review the facility failed to ensure transfer paperwork was sent to the hospital/emergency room for the correct resident for 1 of 3 residents (R2) reviewed for transfers in the sample of 3. The findings include: On 8/12/24 at 8:40 AM, V1 (Administrator) stated in March of 2024 R2 was sent to the hospital with R1's transfer paperwork. On 8/12/24 at 9:31 AM, V4 (Registered Nurse) stated she was the nurse taking care of R2 on 3/6/24 when R2 was sent to the hospital with R1's transfer paperwork. V4 stated R2 pulled out his gastrostomy tube (g-tube) and was sent to the emergency room to have it replaced. V4 stated about 20 minutes after R2 left the facility she received a phone call from an emergency room nurse saying R1 was in the emergency room. V4 stated she corrected the emergency room nurse and informed them that R2 and not R1was in the emergency room. According to V4, the emergency room nurse stated the transfer paperwork sent with R2 had R1's name on it. V4 stated V2 (Director of Nursing) was the one that printed the transfer paperwork for R2. On 8/12/24 at 9:12 AM, V2 stated she printed R1's face sheet and code status and that paperwork was sent with R2 to the emergency room. On 8/12/24 at 11:55 AM, V3 (R1's wife) stated once she became aware that R1's paperwork was sent with R2 to the hospital she went to the hospital billing department. V3 stated R1 had a charge for a tube feeding procedure done on 3/6/24. V3 added that R1 did not have a tube feeding and was never in the hospital on 3/6/24. A hospital statement showed R1 had a charge for a procedure dated 3/6/24. On 8/12/24 at 1:14 PM, V2 stated R1 was not sent to the hospital on 3/6/24 and remained at the facility. R2's progress notes dated 3/6/24 showed he was sent to the emergency room after having his g-tube removed. The facility's Transfer and Discharge (including AMA) policy undated showed for transferring a resident to another provider, for any reason, the following information must be provided to the receiving provider: Contact information of the practitioner, resident representative information, advance Page 1 of 2 145443 145443 08/12/2024 Allure of Zion 3615 16th Street Zion, IL 60099

F 0622 directive information and other information necessary to meet the resident's needs. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 145443 Page 2 of 2