A resident with intact cognition and significant care needs was discharged without prior written notice of the discharge date or location, and the discharge paperwork contained incorrect ombudsman contact information and conflicting destination details. Staff stated discharge notice was often verbal or given at the time of discharge, and the ombudsman was notified only after the resident had already left. The resident and his emergency contact both reported that he was not told where he was going until he was placed in the transport vehicle.
A facility failed to provide two residents with written discharge notices that included ombudsman contact information before discharge, and failed to notify the ombudsman before discharge. One resident had moderate cognitive impairment and the other had severe cognitive impairment; both received NOMNC forms that lacked key discharge details and ombudsman information. Staff stated the NOMNC was the only discharge-related notice routinely given before discharge, and ombudsman notification was typically sent after the resident had already left.
Transfer and discharge documentation not completed for a hospital transfer. A resident with multiple diagnoses and severe cognitive impairment became non-responsive and was sent to the hospital, with family and the attending service notified and belongings later picked up by the family. However, the record lacked a physician order for the transfer, no transfer assessment was completed, and no discharge MDS was initiated or completed, despite staff and DON statements that these documents were required.
Failure to Notify Ombudsman of Resident Transfers and Discharges: The facility did not notify the Ombudsman's office when multiple residents were discharged or transferred, including a resident with intact cognition who planned a home discharge after a NOMNC appeal, a resident sent to the hospital for surgery, and residents with dementia or severe cognitive impairment who were transferred to the hospital or another facility. Records showed no documentation of Ombudsman notification, and interviews confirmed the monthly transfer/discharge reporting process had not been completed for an extended period.
Failure to notify the Ombudsman of a resident discharge. A resident with metabolic encephalopathy, DM2, and HTN was admitted for therapy, then the family raised concerns about room space and chose to take the resident home AMA. Record review and staff interview showed the discharge notice was not sent to the Ombudsman, despite the regulatory requirement to do so.
The facility failed to provide required transfer/discharge notices to residents and to send copies of those notices to the State Long-Term Care Ombudsman. Several residents with conditions such as hemiplegia after stroke, COPD, atherosclerotic heart disease, hepatic encephalopathy, and cirrhosis were discharged to home, hospice, another SNF, or an acute hospital without documentation that the ombudsman received a copy of the discharge/transfer notification. In multiple cases, discharge summaries and forms documented the discharge destination, services, and follow-up appointments, but did not include ombudsman contact information or appeal rights, and there were no physician discharge orders for some residents. Staff, including the Resident Relations Manager, Business Office Manager, and ED, reported that the NOMNC was the only form used as a discharge/transfer notice, acknowledged that it lacked ombudsman and advocacy contact information, and confirmed that they did not send copies of discharge/transfer notifications to the ombudsman, instead emailing only a monthly list of discharged or transferred residents.
A resident with paraplegia, depression, and generalized weakness, who was cognitively intact, requested transfer to another SNF after a staff member told her she was in the wrong (short-term) facility and should look into another placement for long-term care. Social services initiated an SNF-to-SNF referral and discussed transfer procedures with an individual initially treated as a family/POA, later clarified to be a non-family contact authorized by the resident. The facility issued same-day written transfer/discharge notice citing improved health and no longer needing services, and nursing documented the resident’s departure and notification of a POA/family member, but there was no documentation that the OSLTCO was notified at the same time as the resident, nor evidence of discharge planning in the care plan. The resident reported she only signed with an initial, did not understand her appeal rights or the option to consult an ombudsman, and the OSLTCO and facility leadership confirmed that the facility only provided monthly notifications and lacked a specific policy for ombudsman notification for non-emergency transfers.
A resident with multiple medical conditions, who was cognitively intact and receiving PT, OT, and speech therapy, was discharged to a group home after the facility documented that the resident’s health had improved and services were no longer needed. The facility issued a Notice of Proposed Transfer/Discharge on the day of discharge that incorrectly listed the State Agency as the appeals authority and did not send a copy of this notice to the ombudsman. The ombudsman reported only receiving monthly discharge lists and no discharge notices, while the case manager, SS Director, and DON confirmed that copies of proposed transfer/discharge notices were not routinely sent to the ombudsman and that their discharge policy did not specify required notification content for residents, representatives, or the ombudsman.
A resident with multiple orthopedic and neurologic conditions was transferred to another facility after a referral, insurance authorization, and acceptance were documented, and a discharge MDS indicated the resident’s return was not anticipated and that she was cognitively independent. Although staff described a process in which nursing and social services complete discharge summaries with information on home health, DME, follow-up providers, and contact information, they reported that they do not complete discharge summaries or document them in the chart when a resident transfers to another facility, instead sending clinical information and orders as a transfer packet. The MDS coordinator confirmed that this situation met the definition of a discharge and that no discharge summary was present in the record, and leadership acknowledged there was no facility policy specifically addressing discharge summaries.
Two residents were transferred to the hospital for acute changes in condition, including unresponsiveness and hypotension, with documentation in nursing notes, physician visit notes, transfer forms, and discharge MDS assessments indicating hospital transfers with return anticipated, but no written transfer/discharge notices containing required elements were found in their records. One resident had multiple serious conditions including acute respiratory failure, heart failure, and pneumonia; the other had ventilator-associated pneumonia, sepsis, respiratory failure with hypercapnia, and severe cognitive impairment. Staff interviews revealed that Social Services was not involved in notifications, the Medical Records Director only began tracking notifications months after the events and was unsure how mailed notices were tracked, and the liaison who visited residents in the hospital did not provide any transfer/discharge forms. The Medical Records Director confirmed no transfer/discharge notices existed for the two residents and that the form in use contained incorrect appeal and ombudsman contact information, while the Administrator stated she was unaware that this version of the form was being used. Review of the facility’s discharge/transfer policy showed it addressed bed-hold review after emergent transfers but did not address providing written transfer/discharge notices or the required content.
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