Failure to Coordinate Home Health Orders and Communicate PCP Limitations at Discharge
Summary
The deficiency involves the facility’s failure to ensure appropriate communication of critical discharge information and coordination with a home care agency for a resident discharged with orders for skilled nursing and therapy. The resident, who had dementia, heart failure, and a BIMS score of 9 indicating moderate cognitive impairment, was admitted in January 2026 and discharged home on 2/15/2026 with medically necessary home health services ordered by the facility’s Medical Director. The facility’s social worker knew shortly after admission that the resident did not have a community PCP and arranged for a new PCP with an appointment scheduled for 2/26/2026. She also knew that this new PCP would not sign home health orders until the resident was seen in the office, but there was no documentation that this limitation was communicated to the home care agency. The home care agency accepted the referral for services to begin at discharge and conducted an initial assessment on 2/17/2026. Agency records showed that when staff contacted the new PCP for signed orders, they were informed the PCP would not sign until the resident’s 2/26/2026 office visit. The agency then called the facility on multiple occasions, beginning on 2/18/2026, leaving voicemails for the facility social worker to request that the facility’s Medical Director sign the home care orders so services could start before the PCP visit. Progress notes from the agency documented additional voicemails on 2/26/2026 and 2/27/2026, but the facility did not return these calls until 3/5/2026. As a result, the resident did not receive the ordered skilled nursing and therapy services after the initial home care assessment on 2/17/2026. The resident’s family member reported informing the facility a few days after admission that the resident had no PCP and later attempted to contact the social worker on three separate dates after discharge using the correct telephone number, without receiving a return call until 3/5/2026. The family member stated that the social worker had previously assured them that the new PCP had agreed to sign home care orders prior to the office visit, but the social worker could not provide evidence of such an agreement and denied receiving the calls, despite acknowledging the phone number used was correct. The Medical Director stated he had been told by facility staff that the new PCP would sign the orders at discharge and was unaware of the home care agency’s requests for his signature until early March; he indicated he would have signed the orders if he had known the PCP would not sign and that the resident was not receiving services. The record review confirmed there was no evidence the facility communicated to the home care agency that the PCP was new and would not sign orders before seeing the resident, and no timely response to the agency’s and family’s calls, leading to the interruption of ordered home health services following discharge.
Penalty
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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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