Failure to Provide Timely and Proper Transfer/Discharge Notices to Residents, Representatives, and Ombudsman
Summary
The deficiency involves the facility’s failure to follow required transfer and discharge processes, including written notification to residents, their representatives, and the State Long-Term Care Ombudsman at least 30 days prior to transfer or discharge. The facility’s policy "Discharge Plan - Discharge Instructions" required that each resident with an anticipated discharge date receive necessary information and connections to outside services, and that each department interview the resident and continuing care provider to assess post-discharge needs and develop a plan. Despite this, three residents reviewed for transfer or discharge did not receive proper written notices or complete discharge planning consistent with regulatory requirements. Resident #3 had dementia, type II DM, and depression, and their MDS dated 10/13/2025 documented that they were cognitively intact, always understood, and always understood others, with no active discharge plan indicated. A single progress note by Social Worker #1 on 11/17/2025 stated that the representative had been informed the facility planned a lateral discharge to a more secure locked unit and that the resident would transfer to the first facility with an open bed. Social Worker #1 later stated the resident was discharged because they required a more secure unit due to dementia and wandering, but could not locate documentation of recent wandering behaviors or recent wandering/elopement assessments and could not recall who had reported the elopement risk. The transfer/discharge notice for this resident was dated 11/13/2025, cited that the resident’s needs could not be met at the facility, and indicated a lateral transfer to a secure locked unit, but the resident/representative signature line was blank, and there was no evidence the representative received written notice 30 days in advance. The nutritional section of the IDT discharge instructions dated 11/14/2025 for this resident was not completed. Resident #4 had dementia, bipolar disorder, and anxiety disorder, and their MDS dated 09/12/2025 documented that they were cognitively intact, always understood, and always understood others. This resident was discharged on 11/14/2025, and the discharge notice was completed and dated 11/13/2025 by Social Worker #1, but the resident signature line was blank, with no indication of written notice being provided 30 days prior to discharge. Resident #5 had polyneuropathy, bipolar disorder, and anxiety disorder, with an MDS dated 10/16/2025 showing they were usually understood, always understood others, and were moderately cognitively impaired. A late-entry progress note by Social Worker #1, effective 11/17/2025, documented that the resident was notified of discharge and given the discharge notice and summary upon discharge, although the resident had actually been discharged on 11/14/2025. The discharge notice for this resident was dated 11/13/2025 and the resident signature line was marked "Verbal Consent" instead of containing the resident’s signature. This resident later filed an appeal and was readmitted. In an interview, this resident stated staff did not tell them they were moving, that staff came into the room the morning of the move, packed them, and moved them, and that they had to beg to return. Interviews with facility staff and the Ombudsman further described failures in the notification process. Social Worker #1 stated they believed they spoke with Resident #3’s representative on 11/11/2025 about the planned discharge and allowed time for the representative to research two facilities, but did not call the representative prior to the actual move, despite the representative’s request to be notified so they could be present. Social Worker #1 acknowledged that the representative later complained about not being notified of the timing of the move and not receiving a written transfer/discharge notice. Social Worker #1 also stated they sent transfer/discharge notices to the Ombudsman and that three residents, including Residents #3, #4, and #5, were discharged to the same facility on 11/14/2025. However, the email to the Ombudsman with attached discharge transfer notices was dated 11/18/2025, after the transfers had occurred, and the Ombudsman reported they had not been receiving discharge notices from the facility and had only received one notice since July 2025. The Ombudsman stated that residents and their representatives should receive written notice 30 days prior to transfer or discharge and that the Ombudsman should receive a copy the same day, and also noted that the forms used by the facility prior to 11/17/2025 were outdated and did not meet current regulatory requirements. The Administrator stated that if a resident was agreeable to a move, the facility did not believe a 30-day transfer/discharge notice was required, and that if a resident was responsible for themselves, family would not need to be notified of a transfer. The Administrator also stated that they would only issue a 30-day transfer/discharge notice to a resident who was discontent with leaving the facility. The Ombudsman, who also served at the receiving facility, reported learning of the moves of four residents to the other facility after receiving calls from family members and the receiving facility that the residents were unhappy about the move. Overall, the record review and interviews showed that the facility did not provide timely, complete, and properly documented written transfer/discharge notices to the three residents and their representatives, nor did it send copies to the Ombudsman at least 30 days before the transfers or discharges, as required by 10 NYCRR 415.3(i)(1)(i–vii).
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with cerebral palsy and depressive disorder was transferred to the hospital, but the facility did not document completion of the required written bed hold notice for the resident or representative. The facility’s policy called for written bed hold notices at admission and again at transfer, and the SW confirmed the document was not completed.
The facility failed to give two residents written transfer notices and written bed-hold notices when they were sent to the hospital. Records showed one resident had moderate cognitive impairment and the other had intact cognition, but neither record showed a written notice with ombudsman info, appeal rights, or the required bed-hold details such as state policy duration, reserve bed payment policy, or facility bed-hold policy. Staff interviews indicated uncertainty about whether the notices were provided, and the nurse manager stated the facility did not have a process for written transfer notices.
Failure to Provide Bed-Hold Notice and Ombudsman Notification: The facility failed to give a written bed-hold notice when one resident was transferred to the hospital and failed to notify the State LTC Ombudsman of the discharge for two residents. One resident had streptococcal infection and respiratory failure and was transferred to the hospital, while another resident with surgical aftercare and morbid obesity was discharged after leaving AMA. The Administrator confirmed the Ombudsman had not been notified.
Failure to Provide Written Transfer or Discharge Notices: The facility did not give written transfer or discharge notices, with reasons for the move, to three residents or their representatives, and did not send copies to the State LTC Ombudsman. One resident had severe cognitive impairment and was transferred to the hospital twice, another had moderate cognitive impairment and was sent out after a fall and leg pain, and a third had a planned discharge home. The Social Worker and DON stated that only transfer forms or 30-day notices were handled, and the discharge policy did not require written resident notification.
Failure to Document Required Involuntary Discharge Notice: The facility transferred a resident to a sister facility without documented written notice of the involuntary discharge, appeal rights, resident or resident rep notification, attempted contact with the resident’s daughter, or Ombudsman notification. The SW and Administrator acknowledged missing discharge documentation, and the Ombudsman confirmed the required discharge process had not been followed.
The facility failed to notify a resident’s responsible party of the bed hold when the resident was transferred out, and failed to include another resident’s transfer/discharge on the monthly ombudsman report. Record review and staff interview showed the bed hold notice was given to the resident and mailed later to the family, but there was no documentation that the responsible party was notified at the time of transfer. The monthly Action Summary sent to the ombudsman also omitted a resident who was hospitalized and later discharged to another care facility.
Failure to Provide Bed Hold Notice at Hospital Transfer
Penalty
Summary
The facility failed to ensure that a written notice of transfer and bed hold policy was provided to the resident or the resident’s representative when the resident was transferred to the hospital. The facility’s Bed Hold policy dated 2/1/18 stated that two written notices of the bed hold policy and procedures would be issued to the resident, family member, or legal representative, with the first notice given upon admission and the second notice given at the time of transfer for hospitalization. Resident #4 was admitted with multiple diagnoses including cerebral palsy and depressive disorder. Record review showed no documentation of a written bed hold form being completed when Resident #4 was transferred to the hospital on 2/23/26, and the Social Worker stated that she had not completed a bed hold document for the resident when she was transferred in February 2026 and that she should have.
Failure to Provide Required Transfer and Bed-Hold Notices
Penalty
Summary
The facility failed to provide a written transfer notice and a written bed-hold notice for 2 residents who were transferred to the hospital. For one resident, the quarterly MDS indicated moderate cognitive impairment, and the census showed the resident was on hospital unpaid leave after transfer to the hospital; the progress note documented that the resident was transferred and the POA was contacted. For the second resident, the admission MDS indicated intact cognition, and the census and progress note showed the resident was sent to the emergency department and the significant other was notified. For both residents, the medical records did not show that a written transfer notice was given at the time of transfer, including information such as ombudsman information and appeal rights. The records also did not show that a written bed-hold notice was provided to the resident or resident representative with information such as the duration of the state bed-hold policy, the reserve bed payment policy, or the facility's bed-hold policy. During interviews, nursing staff stated they were unsure whether the written transfer and bed-hold notices were given, and the nurse manager stated the facility did not believe it had a process to give residents a written transfer notice and that emails to resident representatives about bed hold did not include the required policy information.
Failure to Provide Bed-Hold Notice and Ombudsman Notification
Penalty
Summary
The facility failed to provide a written Notice of Bed Hold Policy at the time of hospital transfer for Resident 76 and failed to notify the State Long-Term Care Ombudsman of the resident’s discharge. Resident 76 was admitted with diagnoses including streptococcal infection and respiratory failure, and the admission profile indicated the resident was responsible for self. The clinical record showed the resident was transferred to the hospital on 4/26/26, but there was no evidence that the resident or resident representative received the written bed-hold notice at transfer or that the Ombudsman was notified of the discharge. The facility also failed to notify the State Long-Term Care Ombudsman of Resident 78’s discharge. Resident 78 was admitted with diagnoses including surgical aftercare and morbid obesity, and the admission profile indicated the resident was responsible for self. The clinical record showed the resident was discharged after leaving against medical advice (AMA), but there was no evidence that the Ombudsman was notified of the discharge. The Administrator confirmed that the State Long-Term Care Ombudsman had not been notified of the transfer/discharge events for Residents 76 and 78.
Failure to Provide Written Transfer or Discharge Notices
Penalty
Summary
The facility failed to notify residents and/or their representatives in writing, in a language and manner they understood, of transfer or discharge and the reasons for the move, and failed to send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for three residents reviewed for discharge planning. The deficiency involved Resident #7, Resident #8, and Resident #77. Resident #7 was a female resident with diagnoses including NSTEMI, cognitive communication deficit, COPD, acute respiratory failure with hypoxia, and paranoid personality disorder. Her quarterly MDS showed a BIMS score of 3/15, indicating severe cognitive impairment. Progress notes documented that she was transferred to the hospital on 12/09/2025 for chest pain and shortness of breath, and again on 12/28/2025 for abnormal vital signs, altered mental status, and increased confusion. The record contained no evidence that a written transfer or discharge notice was provided to Resident #7 or sent to the State LTC Ombudsman. During interview, Resident #7 stated she did not remember receiving a written letter when sent to the emergency room and said she would have liked to receive one to give to her family member. Resident #8 was a female resident with diagnoses including COPD, type 2 diabetes mellitus without complications, morbid obesity, and chronic hypoxic respiratory failure. Her MDS showed a BIMS score of 12/15, indicating moderate cognitive impairment, and she required mostly substantial to maximal assistance with care. Progress notes documented that after a fall and complaint of leg pain, she was not willing to wait for the facility mobile x-ray, called 911, and was taken to the hospital. There was no evidence that a written transfer or discharge notice was provided to Resident #8 or sent to the State LTC Ombudsman. During interview, Resident #8 stated she had never received a written letter when sent to the hospital and said written information would have allowed her to review the details more carefully later. Resident #77 was a female resident with diagnoses including cognitive communication deficit, muscle wasting, hypokalemia, and diaphragmatic hernia. Her admission MDS showed a BIMS score of 11/15, indicating moderate cognitive impairment, and she required mostly setup or clean-up assistance. Progress notes documented a planned discharge home on 04/02/2026, and there was no evidence that a transfer or discharge notice was provided to the State LTC Ombudsman. The Social Worker stated she had not provided written notification to residents or their representatives regarding transfer or discharge, including the reason for the transfer or discharge, and said the only list sent to the State LTC Ombudsman was 30-day notices. The DON stated nursing staff only provided a transfer form to the hospital and that she did not send a list of discharged residents to the State LTC Ombudsman. The facility's discharge policy did not contain requirements for written notification to the resident or representative regarding discharge.
Failure to Document Required Involuntary Discharge Notice
Penalty
Summary
The facility failed to provide and document written notice of an involuntary transfer/discharge for R100 before the resident was transferred to a sister facility on 8/22/25. The resident’s EHR did not contain documentation of a Notice of Involuntary Discharge, notification of appeal rights, evidence that the resident and/or resident representative were notified, documentation of attempted contact with the resident’s daughter or resident representative, or notification to the Ombudsman program regarding the discharge. During interviews, the Social Worker stated the facility typically issued a NOMNC, discussed appeal rights, reviewed discharge information, coordinated with outside providers, and arranged transportation, but confirmed there was no documentation of attempts to contact the resident’s daughter or of discharge planning for this transfer. The Administrator stated the resident was transferred to the sister facility and that notice had been relayed to the resident, but she could not provide documentation supporting that notification and acknowledged missing pieces in the discharge record. The Ombudsman stated the required discharge process had not been followed, there was no evidence that a Notice of Involuntary Discharge had been issued or that the resident and/or resident representative had been notified, and the Office of Ombudsman for Long-Term Care had not received notification of the discharge.
Failure to Notify Responsible Party of Bed Hold and Report Resident Transfer to Ombudsman
Penalty
Summary
The facility failed to notify a resident’s responsible party of the bed hold policy at the time the resident was transferred from the facility for an emergency room transfer. Record review showed the resident was sent out with a copy of the bed hold policy, and later documentation indicated the policy was mailed to the resident’s family/responsible party on the next business day. However, there was no documentation in the resident’s record showing that the family or responsible party was notified of the bed hold when the transfer occurred. The Social Service Director confirmed that the facility’s process was to give the notice to the resident at transfer and mail it to the responsible party afterward, and the Regional Administrator confirmed there was no documentation showing the responsible party was notified at the time of transfer. The facility also failed to include a resident’s transfer or discharge on the monthly report sent to the ombudsman. Record review showed the resident was admitted to the hospital and later discharged from the facility after being admitted to another care facility from the hospital. The facility’s monthly Action Summary, which the Social Service Director identified as the report sent to the ombudsman, did not list this resident’s transfer or discharge during the reporting period. The Social Service Director confirmed the resident should have been included on the report but was not.
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