Failure to Provide Written Transfer Notices and Complete Bed-Hold Documentation for Hospitalized Residents
Summary
The deficiency involves the facility’s failure to provide required written transfer/discharge notices and complete bed-hold documentation, including the per diem rate, for three residents during hospitalizations. Facility policy titled “Bed Hold Notice” (revised 8/2025) requires that residents and/or their representatives receive written information about bed-hold practices both at admission and at the time of transfer for hospitalization or therapeutic leave, including the duration of any state bed-hold policy, reserve bed payment policy, facility bed-hold policies, and conditions for return. The policy also requires written notice of bed-hold policies within 24 hours of an emergency transfer, documentation of attempts to reach representatives, and retention of a signed and dated copy of the bed-hold notice in the resident’s record. Interviews with the Nursing Home Administrator (NHA) confirmed that the facility only obtains verbal acknowledgement for transfer/discharge and bed-hold notices and does not provide written copies to representatives, and that the per diem rate varies by level of care. For one resident with quadriplegia, epilepsy, dysphagia, insomnia, anxiety disorder, and major depressive disorder, who was cognitively intact per a BIMS score of 15, the facility completed transfer notices for two hospitalizations. The first transfer notice documented the transfer date, a general reason that the transfer was necessary for the resident’s welfare, and specified “Sent out for NP (nasal prongs)” as the reason, and included required agency contact information for appeals. However, the notice was signed only by a facility employee and not acknowledged by the resident or representative, and there was no documentation that the notice was provided in writing in a language understood by the resident or representative. The associated bed-hold notice did not have the reason for the bed hold (hospital admission vs. therapeutic leave) checked and did not include the facility’s basic per diem rate, although it documented that the POA agreed to the bed hold. For the second hospitalization, the transfer notice again was signed only by a facility employee, did not specify the reason for transfer in the “Specify” field, and there was no evidence that the resident or representative received the notice in writing in a language they understood. The corresponding bed-hold notice indicated admission to the hospital and that the representative requested a bed hold and received verbal notice, but again omitted the basic per diem rate. For a second resident with acute respiratory failure with hypoxia, tracheostomy status, and cognitive communication deficit, whose MDS documented short- and long-term memory problems and that the resident was rarely understood and rarely understood others, and who had a guardian, multiple hospitalizations occurred. For each hospitalization, the facility generated a notice of transfer and a bed-hold notice. On one hospitalization, the transfer notice contained a signature line for the resident or representative, but there was no guardian signature, and the bed-hold notice showed an LPN consenting to hold the bed without evidence of guardian consent and without a documented daily rate. On a subsequent hospitalization, the same pattern occurred: no guardian signature on the transfer notice, an LPN consenting to the bed hold, and no daily rate on the bed-hold form. For two later hospitalizations, the transfer notices documented that verbal consent was obtained from the guardian, but there was no evidence that written notices were provided to the guardian, and the bed-hold forms again lacked the daily rate. The NHA confirmed that nurses complete these forms, that only verbal consent is obtained, that no written copies are sent to representatives, and that consent to hold a bed should come from the resident or representative, not from facility staff. For a third resident with chronic respiratory failure, ventilator dependence, encephalopathy, dysphagia, tracheostomy status, and traumatic subdural hemorrhage, who had a legal guardian, similar issues were identified. During one hospitalization, the bed-hold notice showed an LPN signing on the resident representative’s signature line to consent to holding the bed, with no evidence of the guardian’s consent and no daily rate documented. During a later hospitalization, the notice of transfer included a signature line for the resident or representative, but there was no guardian signature, and the bed-hold notice again lacked evidence of guardian consent and did not include the daily rate. In interviews, the NHA reiterated that only verbal consent is obtained for transfer and bed-hold notices, that no written copies are sent to representatives, and that the daily bed-hold rate is only listed in admission paperwork, not on the bed-hold notices themselves. Surveyors noted the absence of written notices to representatives, the lack of resident/representative signatures acknowledging receipt, the improper substitution of staff signatures for representative consent on bed holds, and the omission of the per diem rate on all reviewed bed-hold forms for these residents.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Provide Written Discharge Notice: A cognitively intact resident with osteomyelitis, paraplegia, and chronic pain syndrome was discharged AMA, but the discharge notice in the record had no resident signature confirming receipt. The SSD and CNO initialed the form, and the SSD stated the resident did not receive a copy because he left and did not return, while the CEO was unsure whether written notice was provided.
A resident left the facility against medical advice, but the EMR lacked documentation that the LTC Ombudsman was notified in writing of the discharge. In a separate case, another resident was discharged to the community, but the record lacked a discharge summary with a recap of the stay and medication reconciliation; staff stated nursing and social services were responsible for discharge documentation and planning.
Failure to Send Transfer Information and Provide Bed-Hold Notice: The facility did not document that necessary clinical information was sent to the receiving provider when several residents were transferred to the hospital, including residents with CHF, AFib, dementia, CVA history, respiratory failure, sepsis, pneumonitis, depression, HTN, and weakness. The facility also lacked evidence that written bed-hold policy information was given to residents and/or their representatives at transfer, despite policy requiring notice of bed-hold rights, reserve bed payment details, and the per diem rate to hold the bed.
The facility failed to provide written bed-hold notice to two residents at the time of hospital transfer. One resident was admitted for skilled services and had multiple hospital transfers without documentation of a bed-hold notice, and another resident was sent to the hospital for evaluation without receiving the required notice. Staff confirmed the notices were not provided because the facility does not give written bed-hold notice for residents transferred to the hospital.
A resident’s discharge record was incomplete and did not accurately reflect the resident’s condition at transfer to a boarding care facility. The chart included HF, DM2, cerebral infarction, and aphasia, but omitted dementia with psychosis from the DS and other transfer documents sent by the SSD. The DON acknowledged the DS and MDS were not updated for accuracy, while the MAR received by the boarding care facility did include psychosis.
A resident with obesity, a T-11 to T-12 SCI, multiple rib fractures, and a dislocated elbow was discharged to another SNF, but the facility did not provide recent information about a non-injury fall and an abuse-related sexual behavior allegation. Staff acknowledged no verbal report was given before discharge, and the receiving facility reported the resident arrived without authorization, report, or orders.
Failure to Provide Written Discharge Notice
Penalty
Summary
The facility failed to ensure that a written notice of discharge was provided to Resident #37, who was discharged from the facility. The facility’s policy required written notice of transfer or discharge to the resident, the resident’s representative, and the Office of the State Long-Term Care Ombudsman, and required the notice to include the reason for discharge, the effective date, the destination, and ombudsman contact information. Resident #37 was admitted with diagnoses including other chronic osteomyelitis, paraplegia, and chronic pain syndrome, and an admission MDS documented that he was cognitively intact. The Notice of Discharge or Transfer form in the resident’s record was dated 5/21/26, but there was no resident signature in the verification of receipt section. Instead, the form stated that Resident #37 left the facility against medical advice (AMA) and included the initials of the SSD and CNO. The CEO stated the SSD was responsible for discharges and transfers and that the facility had obtained a current address for Resident #37, but did not know whether he received written notice. The SSD stated that Resident #37 did not receive a copy of the notice because he left the facility and did not return, and there was no address to mail it to him.
Missing Ombudsman Notification and Discharge Summary Documentation
Penalty
Summary
The facility failed to notify the Long-Term Care Ombudsman in writing of Resident 53’s discharge from the facility. Resident 53’s records showed admission to the facility and a discharge return not anticipated MDS dated 05/07/2026 documenting discharge to the community on 05/07/2026. A social service progress note on 05/07/2026 at 1:30 PM stated the resident did not want to stay at the facility and left against medical advice, but the EMR lacked documentation that the Ombudsman was notified of the discharge. The facility was unable to provide such documentation when requested, and administrative staff confirmed the facility had not been notifying the Ombudsman of resident discharges prior to the survey. The facility also failed to complete a discharge summary for Resident 6 that included a recapitulation of the resident’s stay and/or reconciliation of medications after discharge. Resident 6’s admission MDS documented admission to the facility, and a progress note dated 06/29/2026 recorded discharge orders received for discharge to the community. However, the EMR lacked a discharge summary addressing the resident’s stay or medication reconciliation. Staff interviews indicated that nursing staff should ensure discharge orders, complete a discharge assessment to recap the resident’s stay, reconcile medications, and document medication disposition, while social services should open the discharge evaluation and set up the discharge plan. Administrative staff confirmed the record lacked the required discharge summary information.
Failure to Send Transfer Information and Provide Bed-Hold Notice
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider when residents were transferred to the hospital. Review of clinical records showed that Resident R2, who had heart failure, atrial fibrillation, and dementia, had hospital transfers documented on 3/24/26 and 6/23/26, but the record lacked evidence that necessary clinical information was sent with the resident. Resident R5, with diagnoses including unspecified cerebrovascular disease, respiratory failure, dementia, and swallowing difficulty, had a hospital transfer documented on 5/10/26, and the record also lacked evidence that necessary clinical information was communicated to the receiving provider. Resident R43, diagnosed with sepsis, pneumonitis due to inhalation of food and vomit, and swallowing difficulty, had a transfer to the hospital on 5/28/26, and the record lacked evidence of communication of necessary clinical information. Resident R55, with depression, hypertension, and muscle weakness, had transfers documented on 5/29/26 and 6/17/26, and the record lacked evidence that necessary clinical information was communicated. Resident R94, with hypertension, dementia, and heart failure, had transfers documented on 11/13/25, 1/4/26, and 4/10/26, and the record lacked evidence that necessary clinical information was communicated to the receiving health care provider. The facility also failed to provide written bed-hold policy information to residents and/or their representatives upon transfer. The facility policy stated that prior to transfer, written information would be given explaining the resident’s rights and limitations regarding bed-hold, the reserve bed payment policy, the per diem rate required to hold the bed, and the details of the transfer. However, the clinical records for Resident R5, Resident R43, Resident R55, and Resident R94 lacked evidence that they and/or their representatives were provided a copy of the bed-hold policy at the time of transfer. During interview, the DON confirmed that the clinical information should have been provided to the receiving health care provider and that the bed-hold policy should have been provided to the resident or representative upon transfer.
Failure to Provide Written Bed-Hold Notice at Hospital Transfer
Penalty
Summary
The facility failed to provide written bed-hold notice at the time of hospital transfer for 2 of 2 residents reviewed for hospitalizations. Resident #4 was admitted for skilled services and was transferred to the hospital on 3/9/26, 4/28/26, and 6/25/26, but there was no documentation that a written bed-hold notice was provided at the time of any of those transfers. Resident #4 confirmed during interview that they did not receive a written bed-hold notice related to the hospital transfers. Resident #23 was sent to the hospital for evaluation on 6/9/26, and there was no documentation that a written bed-hold notice was provided at the time of transfer. Staff A confirmed that Resident #23 was not provided a written bed-hold notice at the time of the hospital transfer, and later confirmed that Resident #4 and Resident #23 were not provided written bed-hold notices for the hospital transfers because the facility does not provide written bed-hold notice for residents transferred to the hospital.
Incomplete Discharge Documentation for Resident with Dementia and Psychosis
Penalty
Summary
The facility failed to ensure Resident 1’s discharge record was complete and accurately reflected the resident’s clinical condition and care needs at the time of transfer to a boarding care facility. Resident 1’s record showed admission with diagnoses including heart failure and type 2 diabetes mellitus. The MDS dated 4/3/2026 indicated moderately impaired cognitive skills for daily decisions and need for supervision or touching assistance with several ADLs. Earlier records included an H&P stating the resident had capacity to understand and make decisions, while later physician and psychiatry progress notes documented dementia with psychosis, unspecified psychosis, insomnia, and dementia. The discharge summary dated 5/29/2026 stated the resident’s health had improved sufficiently and listed diagnoses including cerebral infarction, aphasia following cerebral infarction, heart failure, and type 2 diabetes, but it did not include dementia with psychosis. The SSD stated she sent the boarding care facility the face sheet, medication review, and H&P, and that dementia with psychosis was not included in the documents sent. The SSD stated she was not aware of that diagnosis and noted miscommunication between the MDs and facility staff. The DON stated the boarding care facility received the MAR, which included psychosis, and acknowledged the discharge summary and MDS failed to update the diagnosis of dementia for accuracy. The facility policy required documentation of all services provided and changes in medical, physical, functional, or psychosocial condition in the resident’s medical record.
Failure to Communicate Recent Fall and Abuse Allegation at Discharge
Penalty
Summary
The facility failed to ensure discharge planning included providing recent information related to an abuse allegation and a recent fall for one resident who was being discharged to another skilled nursing facility. The resident was admitted with diagnoses including obesity, a T-11 to T-12 spinal cord injury, multiple fractured ribs, and dislocation of the right ulnohumeral joint. The admission MDS documented the resident was cognitively intact, had no behaviors, was dependent on staff for bathing and transfers, and was frequently incontinent of bladder and bowel. A social services note documented that the accepting facility had been contacted and discharge was planned. However, progress notes documented the resident had a non-injury fall in the activity room and later exhibited inappropriate sexual behavior toward female residents, including exposing his genitalia and making unwanted sexual propositions, after which he was placed on 1:1 observation. Staff later acknowledged the accepting facility was not contacted to provide a verbal report before discharge, and the accepting facility reported the resident arrived without authorization, without a report, and without orders. Staff also acknowledged they were unsure whether the accepting facility had been notified of the fall or the sexual abuse allegation prior to discharge.
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