F0628

D

Failure to Provide Written Transfer Reasons, Bed-Hold Notices, and Ombudsman Notification

Elgin, Illinois Survey Completed on 12-04-2025

Penalty

No penalty information released

Summary

Surveyors identified that the facility failed to provide required written notifications related to hospital transfers, bed-hold rights, and ombudsman notification for multiple residents. One resident, originally admitted on 12/4/25, experienced hypotension with blood pressures of 73/39 and 79/32, pulse changes, and a temperature increase, leading the NP to order transfer to the ER via 911. Progress notes documented the vital signs, the NP’s order, the 911 call, transport to the hospital, and that the son and daughter were notified, but there was no documentation in the electronic medical record of a written reason-for-transfer form or a bed-hold notice being provided to the resident or POA.

Another resident, originally admitted on 4/15/2018, had three separate transfers related to COPD exacerbations and a complaint of possible heart attack. Progress notes showed episodes of shortness of breath with low oxygen saturation despite nebulizer treatment, 911 calls, transport to the ER, hospital admissions for COPD exacerbation, and a later transfer for chest pain with normal vital signs and oxygen saturation. For all three transfers, the electronic medical record contained no uploaded reason-of-transfer forms or bed-hold notices, and progress notes did not indicate that written notices were given to the resident or representative. In an interview, the DON stated the facility does not give residents or POAs anything in writing regarding the reason for transfer, that nurses only provide clinical information to paramedics, that they do not notify the ombudsman, and that no written reason-of-transfer forms, bed-hold notices, or ombudsman notification documentation could be produced, despite a facility policy requiring written bed-hold notices at admission and each transfer and documentation of ombudsman notifications.