Failure to Develop and Update Discharge Care Plans for Two Residents
Summary
The facility failed to ensure that discharge care plans were developed and updated for two residents who were discharged from the facility. One resident, admitted with a history of stroke, was discharged without an updated discharge care plan. Another resident, admitted with dementia, was discharged without any evidence of a discharge care plan being developed. These deficiencies were identified through clinical record reviews and staff interviews. Interviews with the Social Service Director and Social Services Assistant confirmed that they were responsible for developing and updating discharge care plans but did not do so for these residents. The Director of Nursing also acknowledged that discharge care plans should have been developed to meet the residents' needs. The facility's policy requires social services staff to prepare discharge summaries and post-discharge plans of care in coordination with the interdisciplinary team, which was not followed in these cases.
Penalty
Resources
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Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to consistently provide and document required bed-hold policy notices when several residents were transferred to the hospital. In multiple cases, residents with dementia, psychotic disorders, COPD, chronic respiratory failure, altered mental status, and cerebral infarction were sent out for acute changes in condition, and while transfer notes reflected physician and family notifications, they lacked documentation that the bed-hold policy was discussed with the resident or responsible party. Notices of Transfer or Discharge often indicated a copy of the bed-hold policy was sent with the resident, but the records did not show signed and dated acknowledgment by the resident or appropriate representative, including in situations where a resident had moderate cognitive impairment, short-term memory issues, or a documented need for a proxy and a financial POA authorizing an agent for health care decisions.
The facility failed to provide required written notification to the LTCO for six residents who were transferred from the facility, including five discharged home and one transferred to another facility, as shown by review of the admission/discharge report. A social services staff member stated she only notifies the LTCO when a resident is transferred to a hospital and had not notified the LTCO for residents going home or to another facility, while an administrative staff member stated she expected all transfers to be reported to the ombudsman. The facility could not produce a policy addressing LTCO notification for residents transferred to another facility or discharged home.
Surveyors found that the facility did not provide or document required written transfer/discharge notices and bed-hold policy information for four residents who were sent to the hospital, including individuals with conditions such as dementia, CHF, chronic respiratory failure, and CKD. In each case, progress notes showed that the resident was transferred for acute issues, but the clinical records lacked evidence that written notices were given to the residents or their representatives, and in one case lacked documentation that required information was sent to the receiving provider. Facility leadership, including the ADON, DON, and Administrator, acknowledged that the records did not contain the required documentation, despite a written policy requiring such notices and information exchange.
A resident with intact cognition was discharged to the community without a complete discharge summary that recapitulated the course of treatment. The electronic Transfer/Discharge Report contained basic demographic and clinical data but left key sections blank, including advanced directives, diet type/texture/fluid consistency, and resident-specific information on behaviors, ambulation, bladder/bowel status, feeding, and usual level of functioning, and lacked a signed acknowledgment that a copy was provided to the resident or representative. The SW reported she arranged post-discharge services, provided a medication list and satisfaction survey, and documented discharge arrangements, but was unaware that a comprehensive discharge summary with a recapitulation of the stay was required, and the Administrator confirmed the form used did not include this required summary with interdisciplinary input.
Surveyors found that the facility did not provide or document required written bed-hold policy notices at the time of hospital transfers for three residents. One resident with heart failure and prior stroke was sent to the ER after a decline in condition, another with COPD and severe cognitive impairment was transferred twice for leg evaluation and low HGB requiring transfusion, and a third with hypertension and prior stroke was transferred twice for acute neurologic events including unresponsiveness and seizures. In each case, the clinical record lacked evidence that the resident or representative received written information on the bed-hold duration, reserve bed payment policy, or return rights, and the NHA and DON confirmed this failure for three of six residents reviewed.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Provide and Document Bed-Hold Policy at Time of Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that required bed-hold policy information was provided and documented for four residents transferred to the hospital. For a resident with dementia, psychotic disorder, and autistic disorder who had a BIMS score of 0 indicating severe cognitive impairment, progress notes documented physician notification and guardian notification when the resident was sent to the hospital, but there was no documentation that the bed-hold policy was provided to the responsible party. A Notice of Transfer or Discharge later indicated a copy of the bed-hold policy was sent with the resident. Another resident with COPD and chronic respiratory failure, cognitively intact with a BIMS score of 13, experienced a decline in condition and was transferred to the hospital by ambulance; progress notes documented family notification but did not document any discussion of the bed-hold policy, although a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident. A third resident with altered mental status and cerebral infarction, with a BIMS score of 10 indicating moderate cognitive impairment and documented short-term memory impairment, experienced changes in condition and was transferred to the hospital. Progress notes stated the resident was their own responsible party and that no other notification was completed, and transfer documentation did not include the bed-hold policy, although an untimed Notice of Transfer or Discharge indicated a copy of the bed-hold policy was signed by the resident. A financial power of attorney document in the record showed the resident had designated an agent to act in consent or refusal of health care. For a fourth resident with dementia and osteomyelitis, transfer documentation and a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident, and the transfer form noted the resident required a proxy for decision making. The facility’s policy required that at the time of transfer to a hospital, written notice specifying the duration of the bed-hold policy and information on return to the next available bed be provided, and that a signed and dated copy of the bed-hold notice given to the resident or representative be kept in the resident file, which was not consistently documented for these residents.
Failure to Notify LTCO of Resident Transfers and Discharges
Penalty
Summary
The facility failed to provide required written notification to the Office of the Long-Term Care Ombudsman (LTCO) for six residents who were transferred from the facility, including five residents who were discharged home and one resident who was transferred to another facility. Review of the admission/discharge report for the period from 02/14/26 to 04/14/26 showed these six transfers, but there was no corresponding documentation that the LTCO had been notified of these discharges. During an interview, the social services staff member reported that she only notifies the LTCO when a resident is transferred to a hospital and acknowledged that she had not notified the LTCO when residents were transferred home or to another facility. In a separate interview, an administrative staff member stated that she expected that any transfers from the facility would be reported to the ombudsman. The facility was unable to provide a policy addressing notification of the ombudsman for residents transferred to another facility or discharged home when requested.
Failure to Provide and Document Required Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide and document required written notices of transfer/discharge and bed-hold policies, as well as required information to receiving providers, for four residents who were transferred or discharged to the hospital. For a resident with generalized anxiety disorder, major depressive disorder, and dementia, progress notes showed that the resident was sent to the hospital via 911 for chest pain, lower back pain, and shortness of breath and later returned to the facility, but the clinical record lacked documentation that a written Notice of Transfer/Discharge and the bed-hold policy were provided to the resident or representative, and lacked documentation that required information was conveyed to the receiving facility. The ADON and the Administrator both confirmed there was no documentation that these written notices were provided. For a resident with congestive heart failure and muscle weakness who was sent to the emergency room for painful urination and bloody urine, the clinical record lacked documentation that a Notice of Transfer/Discharge or bed-hold policy was given to the resident or representative, which the DON confirmed. Another resident with chronic respiratory failure and diabetes was discharged to the hospital for respiratory failure, and a resident with chronic kidney disease and dementia was discharged to the hospital, but in both cases there was no documentation that a written notice of transfer/discharge or bed-hold policy was provided to the residents or their representatives. Review of the facility’s Transfer and Discharge policy, dated 1/15/26, showed that the policy required the facility to provide written transfer/discharge notices and bed-hold information to residents and representatives and to provide specified information to receiving providers, but the records for these four residents did not contain the required documentation.
Failure to Complete Required Discharge Summary With Recapitulation of Stay
Penalty
Summary
The facility failed to complete a required discharge summary that included a recapitulation of the resident's stay for one resident who was discharged to the community. The resident was admitted to the facility and had a 5-Day MDS showing intact cognition and active discharge planning. A subsequent discharge-return not anticipated MDS documented that the resident was discharged to the community. Review of the electronic medical record showed an undated Transfer/Discharge Report containing demographic and clinical information such as date of birth, admission date, age, insurance, allergies, primary contact and physician information, diagnoses, most recent vital signs, and immunization history, with a notation to refer to the MAR for current medications. However, several sections of this report were left blank, including advanced directives, diet type/texture/fluid consistency, and resident-specific information on behaviors, ambulation, bladder/bowel status, feeding, and usual level of functioning. There was also no signature or date indicating the resident or representative received a copy of the Transfer/Discharge Report. In interviews, the SW reported she was responsible for long-term resident discharges while a Discharge Planner/Case Manager handled short-term discharges. The SW described her discharge process as arranging post-discharge needs such as follow-up appointments, home health, or equipment, providing a satisfaction survey and a list of medications with administration times, and documenting a progress note outlining discharge arrangements. She stated that when follow-up appointments were arranged, records including provider notes, therapy notes, and medication lists were faxed to the receiving provider. The SW also indicated she was not aware that a discharge summary including a recapitulation of the resident's course of treatment in the facility was required. The Administrator acknowledged that the Transfer/Discharge Report in use contained some required components but did not summarize the resident's course of treatment and that a discharge summary with input from all disciplines should have been completed per regulatory guidelines.
Failure to Provide Required Bed-Hold Policy Notices at Time of Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to provide required written notice of its bed-hold policy to residents and/or their representatives at the time of transfer to the hospital or for therapeutic leave, as required by 42 CFR §483.15(d). Federal regulation specifies that facilities must issue two notices related to bed-hold policies: one that may be provided in advance (such as in the admission packet) and a second written notice that must be given to the resident and, if applicable, the resident’s representative at the time of transfer, or within 24 hours in cases of emergency transfer. The notice must explain the duration of any bed-hold, the reserve bed payment policy, and information about the resident’s right to return to the next available bed. For three of six residents reviewed for hospitalization, the clinical records did not contain documentation that this second written bed-hold notice was provided at the time of transfer. One resident, identified as R8, was admitted with diagnoses including heart failure and a history of stroke, and had moderate cognitive impairment per the MDS. A progress note documented that the resident’s wife requested transfer to the ER due to the resident’s decline, including poor oral intake, vomiting with attempts to eat or drink, and worsening lab results, leading to a 911 call and transfer. Review of this resident’s clinical record did not show any notation that written bed-hold information was provided to the resident or the resident’s representative upon this transfer. Another resident, identified as R15, had COPD and a communication deficit, with severe cognitive impairment noted on the MDS. A progress note described the resident leaving via EMS to a local hospital for evaluation and treatment of the right leg, with the wife and brother-in-law present and reportedly satisfied with the plan of care. A later note documented that the resident’s hemoglobin was 5.5 and that the resident was sent to the hospital for a transfusion, with family made aware of the results and transfer. For both of these hospital transfers, the clinical record lacked documentation that written bed-hold notification was provided to the resident or representative. A third resident, identified as R30, had diagnoses including high blood pressure and a history of stroke, with severe cognitive impairment documented on the MDS. One progress note described a nurse finding the resident slumped over on the commode, unresponsive compared to baseline, drooling, and not following commands, after which the nurse practitioner was notified and the resident was sent to the hospital via squad for evaluation. Another note documented that the resident was seizing, had received medication without effective results, and that 911 was called; EMTs administered medication via an internal jugular line, stopped the seizure, and transported the resident to the hospital, while attempts to reach the son were unsuccessful and the provider was notified. For both of these transfers, the clinical record did not contain notation that written bed-hold notification was provided. In an interview, the Nursing Home Administrator and the DON confirmed that the facility failed to ensure that residents and/or their representatives received written notice of the facility bed-hold policy at the time of transfer for three of six residents reviewed.
Plan Of Correction
The facility will ensure that the residents and/or their representatives receive written notice of the facility bed-hold policy at the time of transfer. Resident R 15 has been discharged from the facility. The BOM educated resident R8 and R30 to the facility bed hold policy Before a resident is transferred to a hospital or the resident goes on therapeutic leave, the nursing facility will provide written information to the resident or resident representative that specifies the bed hold policy. Residents on admission will receive a copy of the facility bed hold policy which will be signed by the resident and uploaded into the medical record. When a resident is transferred to a hospital or is on therapeutic leave the BOM will notify the resident/representative by phone the next day to explain the facility's bed hold policy and confirm whether the resident wants to maintain a bed in the facilityThe DON/Designee will educate the nursing supervisors on the requirement to send a copy of the bed hold policy with the resident on transfer to hospital or on a therapeutic leave Audits will be completed to ensure the bed hold notice was provided and completed promptly for 90% of residents transferring to a hospital or on a therapeutic leave.These Audits will occur weekly times four then monthly times three. Results will be reviewed at the QAPI committee meeting for further recommendations
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