Failure to Provide Transfer-Discharge and Bed-Hold Notifications
Summary
The facility failed to provide transfer-discharge notification documentation and bed-hold notification documentation for Resident 42. Resident 42 was admitted on 1/30/2026 with diagnoses including encounter for surgical aftercare following surgery on the digestive system and unspecified intestinal obstruction. The 2/6/2026 MDS indicated Resident 42's cognitive skills for daily decision making were intact, and the resident required varying levels of assistance with eating, oral hygiene, personal hygiene, toileting, showering, and dressing. Resident 42 was discharged to a general acute care hospital on 2/15/2026, but the medical record did not contain a completed written notice of proposed transfer-discharge. The record also showed a bed-hold notification dated 2/4/2026 that was left blank in the section to be completed upon transfer/discharge, and staff stated the notice of proposed transfer-discharge was not completed and the resident did not receive bed-hold notification upon discharge. The DON confirmed the record did not show that Resident 42 or the ombudsman received the transfer-discharge notice, and did not show that Resident 42 received or was offered bed-hold notification.
Plan Of Correction
F0628 CFR(s): 483.15(c)(2)(iii)(3)-(6)(8)(d)(1)(2); 483.21(c)(2) Transfer and Discharge Process Root Cause: The root cause of the deficient practice was failure to ensure consistent completion and documentation of required transfer/discharge notices and bed-hold notifications prior to or at the time of transfer, along with lack of a standardized process and defined accountability for each step. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: On 2/15/2026, Resident #42 was discharged. Upon review, the facility ensured that the required transfer/discharge notice and bed-hold notification were completed, including documentation that the resident and/or responsible party were informed of appeal rights, bed-hold policy, and return rights. The record was updated to reflect compliance with regulatory requirements, and the responsible party was re-educated on these rights. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 3/17/2026, the Medical Records Director (MRD) conducted a 100% audit of all residents discharged or transferred within the past 30 days to ensure: Presence of transfer/discharge notice Timeliness of notice Bed-hold notification Documentation of resident/responsible party notification, including appeal and return rights Any identified discrepancies were immediately corrected through completion of required documentation, notification to resident/responsible party as applicable, and staff re-education. No additional F0628residents were identified to be out of compliance. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur:To prevent recurrence, the facility has implemented the following systemic changes:On 3/24/2026, the Director of Nursing (DON) conducted mandatory in-service training for licensed nurses, Social Services, and Admissions on transfer/discharge requirements.Education emphasized that all required notifications and documentation must be completed prior to or at the time of transfer/discharge, including:Written transfer/discharge noticeBed-hold notificationNotification to resident, responsible party, and OmbudsmanDocumentation of appeal rights and return policiesProcess Controls Implemented:A Transfer/Discharge Checklist (hard stop) has been implemented and must be completed prior to any transfer or discharge.The checklist requires verification of all regulatory elements before the resident leaves the facility.The licensed nurse is responsible for initiating the transfer and ensuring clinical documentation is complete.Social Services/Admissions are responsible for completing and documenting all required notices and resident/responsible party education.The DON or designee provides oversight and final verification of compliance.Completion Date: 4/13/2026 How the facility plans to monitor its performance to ensure that solutions are sustained: The facility will maintain a 100% compliance threshold for all transfer/discharge requirements. Monitoring Plan: The MRD or designee will conduct daily audits of a minimum of 5 discharged/transfer residents for 4 weeks, followed by monthly audits of 5 records for 2 months. Audits will verify: Presence and timeliness of transfer/discharge notice Completion of bed-hold notification Documentation of resident/responsible party notification Inclusion of appeal rights and return policy Completion of Transfer/Discharge Checklist Corrective Action Loop: Any identified noncompliance will result in immediate correction, including completion of missing documentation and notification as applicable. The responsible staff member will receive re-education prior to the next shift worked. A follow-up audit within daily will be conducted to ensure compliance. Repeated noncompliance will be addressed through progressive discipline per facility policy. Reporting & Oversight: The MRD will report audit findings daily to the Administrator and DON during the monitoring period. The DON and Administrator are responsible for oversight and ensuring corrective actions are implemented. Results will be presented at the Monthly QAPI Committee Meeting, and monitoring will continue until sustained 100% compliance is achieved. Responsible Parties: Licensed Nurse: Initiates transfer and completes clinical documentation Social Services/Admissions: Completes required notices and resident/responsible party education Medical Records Director (MRD): Conducts Daily audits and verifies compliance Director of Nursing (DON) & Administrator: Oversight, enforcement, and QAPI integration Include dates when corrective actions will be completed. The corrective action completion dates must be acceptable to the State Agency. 4/13/2026
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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