Failure to Notify Ombudsman of Resident Transfers and Discharges
Summary
The facility failed to notify the State Long-Term Care Ombudsman of hospital transfers and discharges for two residents out of a sample of twelve. Specifically, one resident with moderate cognitive impairment and an activated Power of Attorney for Health Care was transferred to the hospital due to urinary retention and constipation, but the Ombudsman was not notified of this transfer. Documentation showed that a notice of bed hold and reason for transfer was signed by the POAHC, but the required Ombudsman notification was not completed. Another resident, who had diagnoses including cerebral infarction, chronic headaches, dizziness, and chronic kidney disease, was discharged to an assisted living home without the Ombudsman being notified. Review of the facility's records revealed that the list provided to the Ombudsman only included residents who were readmitted from the hospital and did not account for those who were transferred, discharged, or had passed away. The Nursing Home Administrator confirmed that the Social Worker was responsible for notifications but only sent information about hospital readmissions.
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 chronic pain, ESRD on hemodialysis, heart disease, and mildly impaired cognition was found unresponsive, received CPR, and was transferred to a hospital where death was later confirmed. Although a nurse’s progress note described the event and attempts to phone family, the facility did not complete a discharge/transfer summary, did not document written notice of the transfer/discharge to the resident’s representative, and did not document that required discharge information was communicated to the receiving hospital. The SW and ADON both confirmed the absence of a discharge summary and other required transfer documentation in the medical record, resulting in a deficiency related to discharge documentation and communication requirements.
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.
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 Document and Communicate Required Discharge Information for Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to properly document and communicate a resident’s transfer and discharge information when the resident was sent to the hospital and subsequently died. The resident had diagnoses including chronic pain, end-stage renal disease requiring hemodialysis, and heart disease, and had mildly impaired cognition per a comprehensive MDS assessment. The resident’s designated family contacts were listed in order as a sister, another sister, and then a brother. On the date of the incident, a nurse documented in a progress note that the resident was found unresponsive in the room in the early morning hours, CPR was initiated, and emergency services were notified. The note indicated staff attempted to notify the resident’s brother and then sister as the resident was being transferred to the hospital, and that a follow-up call to the receiving hospital revealed the resident had passed away. However, beyond this progress note, there was no documentation in the medical record regarding the resident’s transfer to the hospital. Record review showed there was no written notice of the transfer/discharge to the resident’s representative, no discharge/transfer summary, and no documentation of required discharge information being communicated to the receiving hospital. The social worker confirmed there was no discharge summary and was unaware of any written notification to the family or documentation regarding collection of the resident’s belongings after death. The ADON also verified there was no discharge summary and no evidence of the required transfer documentation in the resident’s medical record, resulting in noncompliance with the discharge documentation and communication requirements.
Plan Of Correction
F0628 Discharge Process The PoC will what corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident #56 is no longer in the facility. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? Any of the 47 residents residing in the facility have the potential for this practice. The residents who have been recently transferred or discharged had the potential to be affected. A sweep of these residents over a month, completed by nurse managers on 3-25-26, residing in the facility, revealed that residents requiring transfer/discharge are documented in the record with proper information and have not been affected by ths practice What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur. All nurses and the social worker were educated by DON/designee over a period completed by 4/9/2026. Education included facility transfers or discharges of a resident; the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider. Notify the resident and the resident's representative(s) of the transfer or discharge, and the facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. How the corrective action will be monitored to ensure the deficient practice will not recur. DON/Designee audit that each transfer/discharge is properly documented in the resident's chart daily 5x a week X 4 weeks. The information for transfer and discharge includes an e-interact transfer form and bed hold form as well as notification of reason for transfer and significant other notification etc. Results of the audit will be presented to the QAPI team weekly. Audits are done in real time, and if there is a concern, the DON/designee corrects the issue and reeducates the staff involved. Audits in place to ensure discharge forms are done with any discharge by DON/admin and follow-up if missed/re-education for the social services as needed.
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.
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