Failure to Provide Written Bed Hold Notice and Reason for Transfer
Summary
The facility failed to provide a written bed hold notice or reason for transfer to a resident at the time of two separate hospital transfers. According to the facility's own policies, written information regarding bed hold practices and the reason for transfer must be given to the resident and/or their representative both in advance and at the time of transfer. Review of the clinical record for the resident, who had diagnoses including acute kidney failure and paroxysmal atrial fibrillation and demonstrated little to no cognitive impairment, showed no evidence that such documentation was provided during transfers to the hospital on two occasions. Interviews with the resident, their representative, and facility staff confirmed that neither a written bed hold notice nor a reason for transfer was given at the time of either hospital transfer. Nursing staff reported that they did not issue bed hold notifications, stating that this responsibility fell to administration, while the administrator was unable to produce any proof that the required documentation had been provided. The absence of these notifications was corroborated by both the resident and their representative.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident who was cognitively intact and required supervision with ADLs was discharged AMA at the request of a representative, and an LPN mistakenly sent home another resident’s medications and discharge instructions. The error was discovered at shift change when staff could not locate the other resident’s medications, and the discharged resident’s representative later reported the issue to police and returned the incorrect medications and paperwork. The Administrator and DON stated staff realized the error a few hours after discharge, and facility policy required a discharge planning process to ensure a safe transition that met the resident’s needs.
A resident with dementia and multiple comorbidities, who remained largely independent in ADLs, and the resident’s daughter/POA repeatedly requested transfer to another facility with a memory care unit. An LPN documented the resident believed she was supposed to move but there were no discharge or transfer orders, leading to resident agitation. Social services and admissions staff documented that referrals would be sent to several named facilities, but email correspondence and staff interviews showed miscommunication over who was responsible for sending the referrals and confirmed that only one referral was actually sent. This failure to timely and consistently act on the resident and family’s discharge and transfer request did not align with the facility’s discharge planning policy.
A resident with severe cognitive impairment and multiple complex medical conditions was transferred twice to the hospital, but the facility failed to provide required bed-hold notices and written transfer/discharge notices to the resident or representative at the time of either transfer. Documentation showed only clinical information sent to the hospital and a telephone Notice of Medicare Non-Coverage, with no evidence that bed-hold rights or written discharge notices were issued, even after the facility decided the resident would not be allowed to return. The Administrator and Regional Business Office Manager stated that bed-hold notices were only given to Medicaid residents, and the DON was unable to explain the bed-hold process, despite facility policy requiring written bed-hold information and acknowledgment for all residents regardless of payor source.
A resident with multiple complex medical conditions and cognitive impairment was discharged home with family present, but the LPN responsible did not complete the nursing section of the discharge paperwork. There was no documented review of discharge medications and no indication that prescriptions or a three-day supply of medications were offered, despite facility policy requiring a complete discharge summary and medication reconciliation. The Ombudsman and DON both confirmed the discharge documentation was incomplete and that medications were not reviewed or offered.
A resident with complex medical conditions, intact cognition, and dependence on assistance for ADLs lost insurance coverage and was informed of appeal options and potential nonpayment but had no documented assistance from facility staff in applying for or changing Medicaid coverage. After an unsuccessful insurance appeal, the administrator and social services issued a 30‑day discharge notice for nonpayment, and no further social service notes were documented. The resident was later sent to the hospital for severe diarrhea and discharged from the facility the same day; the hospital social worker and the resident’s family reported the facility stated the resident owed a large balance, would not be accepted back, and did not provide an itemized bill or assist with Medicaid changes, despite a policy stating residents appealing discharge would be allowed to return from the hospital.
The facility failed to complete required discharge summaries/recapitulations of stay and to obtain physician discharge orders before discharging two residents. One resident with multiple chronic conditions, including anemia, DM, morbid obesity, bipolar disorder with psychotic features, and CHF, was dependent on staff for several ADLs and was discharged without a documented discharge summary or physician discharge order. Another resident with MS, left hemiplegia, prior CVA, DM, CKD stage IV, and receiving tube feeding was transferred, readmitted, and later discharged to another facility, again without a documented discharge summary or physician discharge order. The DON confirmed these omissions, which were inconsistent with facility policies requiring physician-written discharge orders and comprehensive discharge summaries with recapitulation of stay, final health status, medication reconciliation, and a post-discharge care plan.
Failure to Ensure Safe and Orderly Resident Discharge
Penalty
Summary
The facility failed to provide a safe and orderly discharge for a cognitively intact resident who required supervision with ADLs and had diagnoses including COVID-19, depression, and macular degeneration. The resident was admitted on 09/10/25 and discharged on 09/30/25, leaving against medical advice at the request of the resident’s representative. At discharge, an LPN mistakenly provided the resident’s representative with another resident’s medications and written discharge instructions. The error was not identified until shift change when the night shift nurse could not locate the other resident’s medications in the medication cart. The other resident, admitted on 09/17/25 with diagnoses including cerebral infarction, seizures, and sepsis and with multiple active medication orders, remained in the facility. The resident’s representative discovered that the medications and discharge instructions belonged to a different resident and reported concerns about the resident’s care to the police the following day. The representative informed the police that the facility had acknowledged the error when she called and had asked her to return the medications and discharge instructions so they could be exchanged for the correct ones. A police officer accompanied the representative back to the facility, where the exchange occurred without issue, and the representative confirmed that none of the incorrect medications had been administered to the resident. The Administrator and DON reported that nursing staff realized the error approximately two to three hours after the resident left the facility. Review of the facility’s Discharge/Transfer policy showed that the facility was required to develop and implement a discharge planning process involving the resident or representative and the interdisciplinary team to ensure the resident’s needs were identified and there was a safe transition to a location that met the resident’s needs.
Failure to Timely Process Resident and Family Request for Transfer to Memory Care
Penalty
Summary
The deficiency involves the facility’s failure to provide timely assistance with a resident and family-initiated request for discharge and transfer to another facility with a memory care unit. The resident, who had multiple diagnoses including type 2 diabetes, dementia, nutritional deficiency, acute kidney failure, transient ischemic attack, and atherosclerotic heart disease, had a BIMS score of eight indicating cognitive impairment but was largely independent with personal care and ADLs. On one date, an LPN documented that the resident stated she was supposed to move to another facility that day, but there were no transfer or discharge orders, and the resident became agitated and required redirection. A subsequent progress note documented that the social service worker spoke with the resident’s daughter/guardian, who requested a transfer to a facility with a memory care unit and stated that a referral had been sent. Further review showed that on a later date the Admissions Director spoke with the resident’s daughter, who was also power of attorney, and the daughter again requested referrals to facilities with memory care units. The Admissions Director emailed the Senior Social Worker listing five specific facilities and documented that the daughter wanted referrals sent to those facilities; the Senior Social Worker replied that she would take care of the referrals by the end of that business day. A follow-up email from the Admissions Director several days later requested an update, and the Senior Social Worker responded that she would be in the building on Tuesday and referenced having state in three facilities and things being “a little crazy.” Interviews revealed conflicting accounts: the former social service worker stated he sent a referral on the same day he was terminated; the Senior Social Worker stated she told the Admissions Director to send the referrals; and the Admissions Director stated she was told the Senior Social Worker would send them and verified that only one referral had actually been sent. This sequence of miscommunication and lack of follow-through on the resident/family’s transfer request was inconsistent with the facility’s discharge planning policy, which required safe, person-centered, and compliant discharge planning in collaboration with the resident, representative, and interdisciplinary team.
Failure to Provide Required Bed-Hold and Transfer/Discharge Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide required bed-hold notices and transfer/discharge notices to a resident and/or the resident’s representative at the time of hospital transfers. The resident, admitted on 01/09/2026, had multiple significant diagnoses including nontraumatic intracerebral hemorrhage, atherosclerotic heart disease, hypertension, aortic valve stenosis, malignant neoplasm of the prostate, dysphagia, gait abnormalities, and cognitive communication deficit. An MDS assessment documented a BIMS score of two, indicating severe cognitive impairment. The resident was transferred to the hospital on 01/16/2026 and again on 02/10/2026, with both transfers resulting in hospital admissions for treatment or observation. Record review showed that the discharge/transfer record dated 01/16/2026 did not contain documentation that a bed-hold notice was provided to the resident or the resident representative at the time of transfer, and there was no progress note related to the 01/16/2026 discharge. A Notice of Medicare Non-Coverage was provided by social services to the responsible party by telephone on 02/09/2026, advising that Medicare coverage would end on 02/11/2026 and that financial liability would begin on 02/12/2026, and informing of appeal rights. However, the transfer documentation dated 02/10/2026 only reflected clinical and communication information sent to the hospital and did not show that a written notice of transfer or discharge was provided to the resident or representative at the time of that hospital transfer. Progress notes from 02/10/2026 to 02/12/2026 also lacked documentation that a written discharge notice was issued after the facility determined the resident would not be permitted to return. Further review of the medical record confirmed there was no documentation that bed-hold rights were explained, no bed-hold notice was provided at either the 01/16/2026 or 02/10/2026 transfers, and no signed bed-hold notice was present. The record also lacked any documentation that a transfer/discharge notice was provided to the resident or representative. Interviews with the Administrator and the Regional Business Office Manager established that the facility’s practice was to provide bed-hold notices only to Medicaid residents and not to residents with Medicare or private pay, and the Administrator confirmed that no bed-hold notice was offered or provided in this case and that the bed was not held during hospitalization, leaving no bed available when the resident was ready to return. The DON reported not being knowledgeable about when bed-hold notices should be issued and could not clarify the process followed for the resident’s hospital transfer. Review of the facility’s undated Bed Hold Notice/Policy showed that written information about bed-hold duration, reserve bed payment, and conditions for return was required to be provided to all residents regardless of payment source, with signed and dated acknowledgment, which did not occur for this resident.
Incomplete Discharge Documentation and Medication Review for a Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe and complete discharge process for one resident. The resident had multiple complex diagnoses, including rhabdomyolysis, moderate protein-calorie malnutrition, hypertensive chronic kidney disease stage V, seizures, hypothyroidism, anemia, hyperfunction of the pituitary gland, urinary retention, hyperlipidemia, diabetes insipidus, and hypopituitarism. A discharge MDS assessment showed the resident had cognitive impairment and required setup or cleanup assistance for ADLs. On the day of discharge to home via private car, progress notes documented that family was present, gathered belongings, and discharge paperwork was given. However, the nursing section of the discharge documents completed by the LPN responsible for the discharge was not filled out. Review of the medical record and interviews revealed there was no evidence that discharge medications were reviewed or offered to the resident or family, and the discharge paperwork was incomplete. The Ombudsman reported that the resident was discharged without medication prescriptions and that the discharge paperwork was not filled out completely. The DON confirmed that the discharge documentation was incomplete and that there was no evidence discharge medications were reviewed or offered. The LPN who discharged the resident acknowledged she did not complete the discharge paperwork and did not document reviewing discharge medications or offering a three-day supply, despite this being required by facility policy. The facility’s Transfer and Discharge policy specified that the nurse caring for the resident at the time of discharge must ensure the Discharge Summary is complete, including a recap of the stay, final status, and reconciliation of pre- and post-discharge medications, which was not done in this case.
Failure to Provide Appropriate Discharge Planning and Allow Return After Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to provide timely and appropriate discharge planning and to permit a resident to return following hospitalization after issuance of a 30‑day discharge notice. The resident was admitted with multiple complex diagnoses, including cervical spine fusion, Ehlers‑Danlos syndrome, secondary malignant neoplasm of the lung, depression, anxiety, and neoplasm‑related pain, and had a care plan goal to eventually discharge to an apartment with cancer support. The admission MDS showed intact cognition and a need for supervision or touching assistance with ADLs. On 11/10/25, social services documented that the resident’s insurance coverage ended with a last covered day of 11/08/25, discussed appeal options and upcoming cancer treatment, and noted the resident required assistance with dressing, meal setup, and incontinence care and could not return to her previous residence. There is no documentation that staff provided or documented assistance with Medicaid application or plan changes despite the resident’s dependence on a payor source. On 12/03/25, social services documented that the resident’s appeal of the insurance termination was unsuccessful, that the family was exploring other medical plans with LTC benefits, and that the resident was informed she might receive a 30‑day discharge notice if no payor was secured. The resident expressed that she felt at home and hoped to stay, and there is no documentation that staff offered or provided assistance with the Medicaid application or plan change process. On 12/23/25, the administrator and social services director issued a 30‑day discharge notice for nonpayment, citing failure to pay or to have Medicare or Medicaid pay on the resident’s behalf, with a planned discharge date of 01/22/26. No further social service progress notes were documented in the resident’s record after issuance of the notice. On 01/04/26, nursing documented that the resident was sent to the hospital for nonstop diarrhea, and the record shows the resident was discharged from the facility that same day, with no further documentation after transfer. A hospital social worker later documented that he contacted the facility multiple times and was told the resident owed $28,000, had been given a notice to leave before hospitalization, and that the facility was unable to take her back. The appeal decision dated 01/20/26 found the facility had not met its burden to prove the discharge and denied the facility’s request to discharge the resident. The resident’s daughter and the hospital social worker reported that the facility told the hospital the resident could not return due to nonpayment, that the family did not receive an itemized bill despite requesting it, and that the facility did not assist with changing Medicaid plans. The administrator confirmed there was no documentation that the resident or family did not want to return, no documented communication with the hospital regarding discharge planning, and that facility policy required allowing a resident to return from the hospital during an appeal, which did not occur in this case.
Failure to Complete Discharge Summaries and Obtain Physician Discharge Orders
Penalty
Summary
The deficiency involves the facility’s failure to complete required discharge summaries/recapitulations of stay and to obtain physician discharge orders prior to residents leaving the facility. For one resident admitted with anemia, diabetes mellitus, morbid obesity, bipolar disease with psychotic features, and congestive heart failure, the medical record showed dependence on staff for bathing, toilet hygiene, bed mobility, transfers, and set-up assistance with eating, and documented a discharge date of 10/16/25. However, there was no documentation of a discharge summary or recapitulation of stay, and no evidence that physician discharge orders were obtained before the resident’s discharge. For another resident admitted with multiple sclerosis, left hemiplegia, cerebral infarction, diabetes mellitus, and stage IV chronic kidney disease, the record showed the resident was cognitively intact, dependent for bed mobility, bathing, toileting, and transfers, and received nutrition via tube feeding. This resident was transferred to the hospital, readmitted, and later discharged to another facility on 09/24/25. The medical record lacked documentation of a discharge summary/recapitulation of stay and did not show that physician discharge orders were obtained prior to discharge. The DON confirmed that both residents’ records were missing these required elements, despite facility policies stating that discharges must occur only upon a physician’s written order and that a discharge summary including recapitulation of stay, final health status, medication reconciliation, and a post-discharge plan of care must be completed when discharge is anticipated.
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