Failure to Provide Required Notifications and Complete Discharge Documentation
Penalty
Summary
The facility failed to provide required notifications and documentation related to resident transfers and discharges. Specifically, when a resident with multiple complex diagnoses, including a femur fracture, diabetes, COPD, CHF, and chronic kidney disease, was transferred to the hospital on several occasions, there was no evidence in the clinical record that the resident's family received written information regarding the facility's bed-hold policy. Additionally, there was no documentation that the Office of the Long-Term Care Ombudsman was notified of the resident's hospital transfers, as required by facility policy. The same resident experienced multiple hospital admissions for events such as a transient ischemic attack and stroke-like symptoms, yet each transfer lacked the required notifications to both the family and the Ombudsman. The facility's own bed-hold policy stipulated that written information about bed-hold duration and payment policies must be provided at the time of transfer, and that a copy should be sent with the resident to the hospital for the representative. The discharge and transfer policy also required that the Ombudsman be notified of transfers, but these steps were not documented as completed. In a separate case, another resident was transferred to a different facility to be closer to family. The discharge summary for this resident was incomplete, lacking a recapitulation of the resident's stay and a reconciliation of medications, despite the facility's policy requiring these elements to be included in the discharge documentation. Administrative staff confirmed that the medication reconciliation section was not completed, and acknowledged that it should have been done according to policy.