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:
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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