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.
Failure to Provide Timely Written Discharge Notice: A resident with intact cognition, decision-making capacity, and assistance needs for ADLs was planned for discharge to an ALF after IDT and social services discharge planning discussions. However, the facility did not provide the required written Notice of Proposed Transfer/Discharge at least 30 days in advance, and the SSD stated it was withheld because there was no physician order yet. The DON acknowledged the transfer/discharge policy was not followed, and the resident stated the discharge date was not clearly explained and that he and his family should have received 30 days’ notice.
Bed-Hold Notice Not Properly Documented and Resident Not Readmitted to First Available Bed: A resident with hemiplegia, hemiparesis, and no decision-making capacity was transferred to a GACH with a 7-day bed hold order. The facility did not obtain a signed bed-hold notice or provide written notice to the RP at transfer, despite policy requirements. When the resident was ready to return after the bed-hold period, the DON declined readmission due to acuity, even though the Admin stated the facility had the capacity, including an empty isolation room and ability to care for BiPAP and wound needs.
Failure to Provide Written Bed Hold Notice Upon Transfer: A resident with leukemia, fractures, severe cognitive impairment, and no capacity to make decisions was transferred to a GACH, but the Bed Hold Notification was not completed in writing upon transfer. The RN Supervisor stated the transfer section was blank and the record did not show the responsible party was notified in writing of the 7-day bed hold, despite facility policy requiring written notice and a copy in the chart.
Bed Hold Policy Not Followed for Returning Resident: A resident was sent to an acute care facility and later returned within the seven-day bed hold period, but her belongings had been boxed up and she was placed in a different room and bed instead of being returned to her prior assignment. The resident had signed for up to seven days of bed hold, and the DON acknowledged the bed should have been held through the full period.
Bed-Hold Notice Not Properly Documented for Hospital Transfers: A resident with severe cognitive impairment and total dependence on staff was transferred to the hospital twice for acute changes in condition, and the facility’s Bed-Hold notices were not signed or fully completed to show the resident’s representative was notified and acknowledged the bed-hold information. The RNS and DON confirmed the forms were incomplete and did not reflect the facility’s written bed-hold and transfer notification policies.
A facility failed to readmit a resident after transfer to an acute care hospital. The resident was an LTC custodial resident, and records showed an appeal for readmission was granted after the facility refused to accept the resident back. Social services documented that the family was told the resident would be admitted the next day, and the Administrator and DON later verified the resident should have remained in the facility.
A facility failed to send required written transfer notices to the Ombudsman for a resident who was sent to the hospital multiple times for evaluation and treatment. The EMR had no written transfer notices for those hospitalizations, and SS stated the resident and Ombudsman were not notified and that no policy/procedure existed for written discharge/transfer notice.
A resident transferred to the hospital for NG tube placement due to failure to thrive was not given a written 7-day bed hold agreement before the transfer, even though the facility’s policy required written notice to the resident and/or representative for hospital transfers or therapeutic leave. The resident’s representative confirmed she did not receive the form, and MR and the DON could not provide a bed hold agreement for the transfer.
Failure to Notify Ombudsman of Resident Discharge: The facility failed to notify the LTC Ombudsman of a resident discharge for one of three sampled discharged residents. A resident with acute respiratory failure with hypoxia, Type II DM, and HTN was discharged home with home health services and DME, but the MRD could not locate documentation showing the discharge notice was faxed to the Ombudsman. RN and DON stated the discharge notification should have been sent as required by the Notice of Transfer or Discharge.
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