Eagle Rock Health: Transfer Records Missing - ID

Eagle Rock Health and Rehabilitation of Cascadia completed electronic transfer forms for each hospital discharge but failed to document that required medical information accompanied the patients. The pattern affected the same two residents repeatedly between November 2025 and March 2026.

Resident #11 made three separate trips to the hospital during this period. On November 16, 2025, staff sent him for shortness of breath. He returned to Eagle Rock, only to be discharged again on February 23, 2026, for pain, diarrhea, and elevated heart rate. A third transfer occurred March 7, 2026.

In each case, the facility's electronic records showed staff completed the required eINTERACT Transfer Form but contained no documentation proving they sent the resident's care plan goals and advance directive information to the receiving hospital.

Resident #28, who lives with heart failure and chronic obstructive pulmonary disease, experienced similar gaps in transfer documentation. Staff sent her to the hospital November 15, 2025, due to altered mental status. She was discharged again March 19, 2026, for chest pain.

Her medical record also lacked documentation that required information traveled with her to either hospital.

The Chief Nursing Officer acknowledged the systematic failure during the April 2 inspection. She told inspectors that nurses had completed the electronic charting in their Point Click Care system but had not documented what forms were sent to the hospital with residents.

"Should have," she said.

The missing documentation represents more than paperwork. Care plan goals outline specific treatment approaches tailored to each resident's conditions and preferences. Advance directives specify whether residents want aggressive medical interventions, resuscitation attempts, or comfort care only.

Without this information, hospital staff must make treatment decisions based solely on immediate symptoms rather than the resident's established care preferences and long-term health strategy.

Both residents required multiple hospitalizations within months of each other. Resident #11's transfers involved respiratory distress, gastrointestinal issues, and cardiac symptoms. Resident #28's altered mental status and chest pain suggested complications from her underlying heart and lung conditions.

The electronic transfer system, eINTERACT, was designed specifically to improve communication between nursing homes and hospitals. The forms prompt staff to include essential medical information that emergency departments need to provide appropriate care.

Eagle Rock staff used the electronic system but failed to complete the communication loop. They documented the transfers internally but did not ensure hospitals received the comprehensive medical picture each resident needed.

The Chief Nursing Officer's admission revealed that this was not an isolated oversight but a systematic problem with the facility's transfer process. Staff consistently completed internal documentation while failing to verify that critical information reached the hospitals.

For Resident #11, this meant three separate emergency departments received him without knowing his care goals or end-of-life preferences. Each hospitalization became a medical puzzle missing essential pieces.

Resident #28's situation was equally concerning. Her heart failure and COPD require careful management, and her advance directives likely contained crucial guidance about her treatment preferences for cardiac episodes and breathing crises.

The inspection found that some residents were affected by this documentation failure, though the specific number beyond these two cases was not detailed in the report.

Federal regulations require nursing homes to provide receiving facilities with pertinent medical information during transfers. This includes care plan goals that reflect each resident's individual needs and advance directives that honor their healthcare wishes.

Eagle Rock's electronic charting system captured the basic transfer information but missed the human element that makes the difference between appropriate care and medical guesswork.

The facility's failure to document proper information transfer left vulnerable residents in hospital emergency departments without the medical context needed to honor their care preferences and treatment goals.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Eagle Rock Health and Rehabilitation of Cascadia from 2026-04-02 including all violations, facility responses, and corrective action plans.

Additional Resources

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