Failure to Complete and Implement Effective Discharge Planning for Two Residents
Summary
Surveyors identified a deficiency in the facility’s discharge planning process for two residents who were discharged to an independent living facility (ILF). Resident 2, admitted with cognitive communication deficit, depression, and stage 3 chronic kidney disease, was discharged without assistance in obtaining a government ID and debit card that were known to be missing. The Social Services Director acknowledged that Resident 2 did not have these items and that she did not assist him in acquiring them before discharge, despite knowing he needed them to pay rent at the ILF. The Social Service Note documented that discharge instructions, including follow-up appointments and a medication plan, were reviewed, but there was no evidence that the facility ensured Resident 2 had the financial and identification resources necessary for his planned living arrangement. Record review for Resident 2 showed a physician’s order for home health services and a primary care physician appointment after discharge, but the Discharge Summary and Post-Care Instructions form had blank fields for the primary care physician’s name, appointment details, phone number, address, and pharmacy information. A copy of this incomplete document was given to the resident at discharge. The Independent Living Facility owner reported being unaware that Resident 2 lacked an ID or debit card and stated that the resident left the ILF and did not return. The home health RN reported that Resident 2 did not have a medication list at the ILF and that there was no established pharmacy or primary care physician. The case manager confirmed that the medical record lacked documentation of a pharmacy for medication pick-up, did not indicate that a primary care physician was established, and contained no discharge planning documentation until the day of discharge. For Resident 3, who had diagnoses including myopathy, COPD, epilepsy, anxiety disorder, and spinal stenosis, the discharge documentation was also incomplete. The Discharge Summary recorded the discharge date but did not include the discharge location or transportation method, although the Social Services Director later stated that the resident was discharged to an ILF. The Discharge Summary and Post-Care Instructions for Resident 3 similarly had incomplete information in the Post-Discharge Plan of Care Services, Referrals, and Equipment section, with blank fields for primary care physician name and appointment details, phone number, address, and pharmacy information, even though a copy was provided to the resident at discharge. Review of the facility’s policy on Discharge Summary and Plan showed that staff were required to assist in finding a primary care provider if the resident had none and to document their efforts, but the records for both residents lacked this documentation and complete discharge planning details.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Send AD During Hospital Transfer: A resident with anoxic brain injury, pulmonary HTN, and paraplegia was transferred to the hospital after seizure activity and decreased responsiveness. The facility sent the POLST with the transfer paperwork but did not send the resident's AD, which stated a wish to receive artificial nutrition and hydration indefinitely; the POLST instead indicated no decision made for medically assisted nutrition and that an AD was not available. The DON acknowledged the AD was not sent to the receiving hospital.
Missing Written Transfer and Bed-Hold Notices: A resident with severe cognitive impairment and nonverbal status was transferred by ambulance to the ED for labored respirations and a change in LOC. The chart lacked evidence that written transfer and bed-hold notices were sent with the resident or provided to the resident’s representative, and staff stated these notices were not routinely sent with the resident.
A facility failed to notify the Ombudsman of a resident discharge. The resident completed skilled PT/OT, was independent with ADLs, had intact cognition, and was discharged to home/community with a plan to transfer to Assisted Living. The DON and LSW said they did not know the Ombudsman had to be informed of voluntary discharges, and the Ombudsman reported she had only been notified of hospital transfers, not all discharges and transfers as required by policy.
The facility failed to document that necessary resident information was sent with three hospital transfers, including care plan goals, advance directive information, ongoing care instructions, and resident representative information. It also failed to notify two residents or their representatives of the bed-hold policy and failed to notify the State LTC Ombudsman for three hospital transfers. The DON and Regional Director of Clinical Services confirmed the missing documentation and notifications.
A resident admitted for rehab after a short hospital stay, with diagnoses including anemia, CAD, DM, and long-term anticoagulant use, left the facility AMA. The record showed the daughter was present, the PCP was updated, and a MAARC report was filed, but the discharge tracking log did not show that the Ombudsman was notified. The Admin confirmed the facility did not routinely report AMA discharges to the Ombudsman.
Failure to Provide Bed-Hold Notice at Transfer: The facility failed to ensure that written bed-hold policy notice was given to the resident and/or representative at the time of hospital transfer for four residents. The affected residents had diagnoses including dementia, CKD, diabetes, HTN, AFib, anxiety, and depression, and were transferred for issues such as abdominal pain, coughing up blood, altered mental status, elevated BP, UTI, and pneumonia. The NHA confirmed Medicaid residents were not provided bed-hold information upon transfer, and the DON and NHA confirmed the lapse.
Failure to Send Advance Directive During Hospital Transfer
Penalty
Summary
The facility failed to ensure appropriate information was provided to the receiving hospital during the transfer of a resident who had an anoxic brain injury, pulmonary hypertension, and paraplegia. The resident was transferred to the hospital on 7/25/26 after seizure activity and altered responsiveness were documented in nursing notes, and the on-call NP directed that the resident be sent to the emergency room for further evaluation. The charge nurse called 911, notified the resident representative, and the resident was transported by ambulance to Mat-Su Regional Medical Center. During review of the transfer paperwork, the facility sent the resident's POLST with the hospital transfer but did not send the resident's Advance Directive. The resident's AD, dated 11/24/24, stated that the resident wished to receive artificial nutrition and hydration indefinitely, while the POLST dated 12/30/25 documented medically assisted nutrition as "No decision made (standard of care provided)" and indicated that an advance directive was not available. The DON reviewed the transfer documents and acknowledged that the AD did not get sent to the receiving facility. The facility policy required staff to inform emergency medical personnel of a resident's advance directive and provide a copy of the AD or POLST when transferring the resident, and the transfer/discharge policy required appropriate information to be communicated to the receiving health care institution or provider.
Missing Written Transfer and Bed-Hold Notices
Penalty
Summary
The facility failed to ensure written transfer notices were provided as soon as practicable for 1 resident who was transferred to the emergency department by ambulance for labored respirations and a change in level of consciousness. The resident had severe cognitive impairment on the comprehensive MDS, was noted in a progress note to sleep most of the time, have a decreased level of consciousness, and be nonverbal, and her daughter was designated as her legal representative. The transfer note documented that verbal consent was obtained by phone from the daughter for a bed hold. A review of the resident’s medical record found no evidence that written transfer and bed-hold notices were sent with the resident to the hospital or provided to the resident’s representative. During interviews, nursing staff stated that paperwork sent with residents included items such as a face sheet, diagnoses, POLST, medications, immunizations, vital signs, and progress notes, and that bed holds were handled on a paper form kept at the facility and scanned into the chart. Staff also stated that written transfer notices and bed-hold forms were not sent with the resident or provided to the resident’s representative, and the DON stated she did not know whether a written transfer notice and/or written bed-hold notice was required to be sent with the resident or provided to the resident’s representative.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to notify the ombudsman of 1 of 2 sampled resident discharges involving R49. R49’s accepted discharge MDS assessment dated 6/17/26 identified that he was discharged to his home/community with return not anticipated. The discharge summary dated 6/25/26 stated that after completing skilled PT and OT, R49 was independent with ADLs, his cognition was intact, and the decision was made to transfer him to Assisted Living after discharge. During interviews, RN-D reported that R49 had originally transferred from another facility after hospitalization, was admitted for skilled therapies, and later he and his family decided to discharge to a local Assisted Living facility. The DON and LSW stated they were not aware the ombudsman had to be informed when residents voluntarily discharged to the community and therefore had not done so. The Ombudsman reported she had only been informed of residents going to the hospital and stated she should have been notified of all resident discharges and transfers regardless of destination. The administrator stated she was not aware that appropriate notifications of transfers or discharges were not being provided to the Ombudsman. The facility’s January 15, 2026 Discharge and Transfer policy stated that when a resident was transferred or discharged, the location must send a notification to the Office of the State Long-Term Care Ombudsman.
Failure to Communicate Transfer Information and Notify of Bed-Hold and Ombudsman
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider for three of five residents sampled with facility-initiated transfers. For Residents R4, R10, and R72, the clinical record did not show documentation that the facility sent specific information to the acute hospital, including care plan goals, advance directive information, specific instructions for ongoing care, resident representative information, and other information needed to meet the resident’s specific needs at the receiving facility. Staff interviews confirmed that the resident information sent with these transfers was not documented. The facility also failed to notify the resident or the resident’s representative of the bed-hold policy for two hospital transfers, Residents R4 and R10, and failed to notify the Office of the State Long-Term Care Ombudsman for three hospital transfers, Residents R4, R10, and R72. Resident R4 had diagnoses including diabetes, depression, and multiple sclerosis and was transferred to the hospital and later returned to the facility. Resident R10 had diagnoses including diabetes, cerebral infarction, and depression and was also transferred to the hospital and returned. Resident R72 had diagnoses including high blood pressure, chronic pain, and COPD and was transferred to the hospital and returned the same day. The DON and Regional Director of Clinical Services confirmed the missing documentation and the lack of Ombudsman notification.
Failure to Notify Ombudsman of Resident AMA Discharge
Penalty
Summary
The facility failed to notify the Ombudsman of a resident transfer/discharge for 1 of 2 residents reviewed for Ombudsman notification. The resident was admitted for rehabilitation after a short hospital stay and had diagnoses including anemia, coronary artery disease, diabetes, and long-term use of anti-coagulants. The medical record showed an admission MDS dated [DATE], an Entry Tracking record dated 6/22/2026, and a PPS-Discharge Assessment marked return not anticipated. Progress notes documented that the resident left the facility against medical advice at 2:00 p.m., with the daughter present and the primary care provider updated, and that a MAARC report was filed later that day. Review of the May and June discharge tracking log did not identify that the Ombudsman had been notified of the resident's transfer/discharge, and the Administrator confirmed during interview that the facility did not routinely report residents who left AMA to the Office of the Ombudsman and that the Ombudsman was not notified when this resident left.
Failure to Provide Bed-Hold Notice at Transfer
Penalty
Summary
The facility failed to ensure that the resident and/or the resident representative received written notice of the facility bed-hold policy at the time of transfer for four of eight residents reviewed for hospitalization. Federal regulation S483.15(d) requires facilities to provide written information about bed-hold policies prior to and upon transfer, and the facility policy stated that residents are to receive this information well in advance of transfer and again at the time of transfer, or within 24 hours for an emergency transfer. Review of the clinical records for Residents R9, R58, R62, and R98 failed to reveal documentation that the written bed-hold notice was provided upon transfer to the hospital. Resident R9 had diagnoses of diabetes, cirrhosis of the liver, and dementia, with severe cognitive impairment, and was transferred to the hospital for abdominal pain. Resident R58 had diagnoses of high blood pressure, chronic kidney disease, and dementia, with severe cognitive impairment, and was transferred for coughing up blood. Resident R62 had diagnoses of atrial fibrillation, diabetes, and high blood pressure, and was transferred for increased altered mental status and elevated blood pressure. Resident R98 had diagnoses of anxiety, depression, and dementia, and was transferred and admitted to the hospital for a urinary tract infection and pneumonia. The Nursing Home Administrator confirmed that residents with Medicaid as a payer source were not provided bed-hold information upon transfer to the hospital, and the DON and Nursing Home Administrator confirmed the facility failed to ensure the required written notice was provided.
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