Missing transfer, bed-hold, and Ombudsman notifications
Summary
The facility did not ensure that required transfer/discharge notices, bed-hold information, and Ombudsman notifications were documented for multiple residents who were transferred or discharged. The sampled residents included R105, R103, R13, R8, R14, and R66. The facility policy titled Transfer and Discharge, implemented 4/15/26, stated that transfer/discharge notices must include the reason for transfer or discharge, the effective date, the receiving location, appeal rights, appeal form information, assistance information, and the Ombudsman contact information, and that the facility would maintain evidence that notice was sent to the Ombudsman. R105 was discharged home and the record showed discharge paperwork and belongings were taken home, but the facility could not provide evidence that the Ombudsman was notified. R103 had a planned discharge home, and the facility also could not produce evidence of Ombudsman notification. R13, who had resided in the facility since 8/19/20, had an activated POAHC and was on hospice services when sent to the hospital for a change in condition; the record did not include documentation of bed-hold information or transfer notice requirements, and the facility stated it did not have the paperwork. R8 was sent to the hospital twice for acute respiratory failure and later hypotension/lethargy, but the facility did not document bed-hold information or transfer notices for either hospitalization, and the Ombudsman was not notified. R14 experienced changes in condition and was transferred to the hospital twice, but the record did not show bed-hold information or transfer notices were provided to R14 or the representative, and the Ombudsman was not notified. R66 had multiple hospital transfers for changes in condition over several months, and the facility did not document bed-hold information or transfer notices for any of those hospitalizations; the NHA stated the facility did not have the documents and that the Ombudsman was not notified. During interviews, the NHA stated the Business Office Manager had left and was not completing Ombudsman notifications, and the facility acknowledged that monthly Ombudsman notifications had not been made.
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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