Failure to Provide Required Written Transfer, Bed-Hold, and Discharge Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide required written discharge and transfer information, including notices to residents, their representatives, and the Ombudsman, as well as required bed-hold notifications and discharge summaries. For one resident who fell and was transferred to the hospital, the record contained a transfer notice indicating the transfer was due to an unwitnessed fall, but the social services worker stated he did not send a copy of this transfer notice to the Ombudsman. Another resident reported being sent to the ER due to concerns about surgical incisions and stated she did not receive a written transfer notice or a written bed-hold notice. Review of her medical record confirmed there was no written transfer notification that included appeal information or Ombudsman contact information, and no written bed-hold notification for her hospital transfer. A third resident’s EMR showed a transfer to the hospital due to changes in wound appearance and dehiscence, but the record did not contain a written bed-hold notification for that transfer. The corporate nurse confirmed that staff did not complete a written bed-hold notification for this resident and that staff were expected to send copies of transfer notices to the Ombudsman. The social services worker also confirmed he did not send the Ombudsman copies of written notices of transfers. The administrator confirmed that for the resident transferred for surgical incision concerns, staff did not complete a written transfer notification or a written bed-hold notification, despite an expectation that staff complete these notices, provide copies to the resident or representative at the time of transfer, and send a copy of the transfer notice to the Ombudsman. For another resident who was admitted and later left the facility AMA with family, the progress note documented that the resident was not given medications or discharge paperwork at the time of departure. Review of this resident’s medical record showed there was no discharge notice, no discharge summary, no recapitulation of the stay, no final summary of the resident’s status with individualized care instructions, and no medication reconciliation between pre-discharge and post-discharge medications. The Social Service Coordinator confirmed that the resident’s record did not contain documentation of a discharge summary, discharge notification, recapitulation of stay, or medication reconciliation, that a written discharge notification was not sent to the Ombudsman, and that there was no documentation in the record of a report made to APS for this discharge, although the coordinator stated it had been reported.
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