Incomplete transfer/discharge notice: A resident with sepsis, anxiety disorder, encephalopathy, and moderate cognitive impairment was ordered discharged home per resident/family request, but the Notice of Proposed Transfer/Discharge Form did not include the reason or basis for the discharge. The MRD and an RNS stated the form should have been completed to explain why the resident was transferring/discharging and to notify the family and ombudsman.
A resident with an unstageable sacral pressure ulcer, cognitive impairment, and significant ADL dependence was discharged back to an ALF with wound care orders and no listed home health PT/OT/RN continuation of care. The SSD said she was not aware of the wound before discharge and that the ALF was not an appropriate setting, while ALF staff reported there were no on-staff nurses and the facility had not coordinated with a home health agency before discharge.
A resident who spoke Vietnamese and had capacity to make decisions was transferred to another SNF, but the Notice of Proposed Transfer and Discharge was written in English and the record did not show who explained it, what language was used, or whether the resident understood it. The chart also lacked documentation of the transfer time, transportation mode, representative notification, and report to the receiving SNF. The LTC Ombudsman was notified only after the resident had already left.
Failure to Notify Ombudsman and Family of Discharge and Appeal Rights: A resident with ESBL-resistant infection, dementia, and sepsis had severely impaired cognition and needed moderate ADL assistance, yet the facility discharged the resident from bed hold without completing the required transfer/discharge notice. The LVN, BOM, and DON all described missing signatures, no fax confirmation, and no written notice to the resident's representative, and the family member stated he was not told the resident was being discharged or given appeal rights information.
A resident was told by Social Services that he would be discharged to a shelter with only two days' notice, but he did not receive the required written discharge notice. The Ombudsman also was not notified and learned of the attempted discharge only after a family member called. The SSD stated she was unaware of the written notice requirements and had not been documenting discharge planning in the resident's record.
The facility failed to give 51 residents and/or their representatives the required 30-day notice before facility-initiated transfers, with residents moved within 10 days of notification. Interviews showed several cognitively intact residents were distressed by the moves, including concerns about distance from family and friends and limited ability to visit. One resident’s RP reported receiving a call from the resident about the transfer before the closure letter arrived, and the ADM confirmed the closure letters were mailed shortly before the transfers. The facility policy required at least 30 days’ notice before a facility-initiated transfer or discharge.
Failure to Provide Required Advance Discharge Notice: The facility did not provide proper 30-day written NPTD notice for four residents. Two residents received only 3 and 8 days' notice before discharge, and two residents were not given the NPTD during their stay. The SSD and DON both stated the residents should have received 30-day advance notice, consistent with facility policy and federal regulation.
A resident with a G-tube and severe cognitive deficits was discharged without the feeding pump needed for prescribed TF, and the family was not taught the revised bolus feeding method before leaving. Staff also failed to individualize the discharge care plan and did not send complete clinical records, including the H&P, face sheet, discharge summary, progress notes, AD, and TF instructions, to the HHA.
A resident with enterocolitis, COPD, and acute respiratory failure was transferred to an acute care hospital for hypotension, but the facility did not complete the bed hold notification form to show the transfer/discharge or document that the resident or representative was given the written 7-day bed hold policy. The QAN and DON acknowledged the form was incomplete, the spouse could not be reached, and the record did not show an order for the transfer or bed hold.
Failure to Provide Required Transfer and Discharge Notices: The facility did not give required written transfer/discharge notice to one resident and gave same-day discharge notice to two others without a documented exception. Records showed one resident had no written notice at all, while two residents were discharged to another SNF the same day they were notified. The OMB was not notified before one discharge, and interviews showed residents were not given clear notice or explanation of the discharge process.
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