Medication Error During Discharge: A resident with severe cognitive impairment was discharged home with a family member and later found to have received another resident’s Seroquel instead of the correct meds. The LPN gathered blister packs from the med cart but did not verify them before handing them over, and the resident’s roommate was the one prescribed quetiapine. After the family reported lethargy and the wrong medication, the resident was sent for medical evaluation.
A resident with post-op pain needs and an order for Oxycodone was discharged with paperwork listing the narcotic, but the medication was not sent home. The RN responsible for discharge education and med reconciliation failed to ensure the resident was told the narcotic had to be signed out and failed to provide the Oxycodone at discharge; the resident later called reporting severe pain, and the DON stated the family returned later to retrieve the medication.
Failure to Notify Ombudsman of Resident Discharges: Two residents with intact cognition and active discharge plans to return to the community were discharged home, one with home health services and follow-up care. Facility records and staff interviews confirmed the Ombudsman was not notified of either discharge because staff only reported AMA discharges or hospital transfers, and the discharge policy did not address Ombudsman notification.
A resident with bipolar disorder, dementia, and anxiety, who was independent in ADLs but care planned as an elopement risk, was allowed to go on LOA with a friend after the conservator consented. Nursing late entries documented the LOA, the resident’s failure to return, multiple unsuccessful attempts to contact involved parties, notification of police and clinical leadership, and discovery that most belongings were gone, while the census showed the resident as discharged. However, the Director of Social Services did not document the LOA outcome or the discharge in the clinical record and did not submit the required discharge notification to the State LTC Ombudsman portal, stating unawareness that non-return from LOA constituted a discharge, despite a facility policy requiring detailed discharge documentation.
A resident with acute respiratory failure, septic shock, intact cognition, and high ADL assistance needs was discharged home with documentation stating that skilled home care services (nursing, PT, OT, and HHA) had been arranged. Post-discharge, the listed home care agency reported having no record of the resident and not serving the resident’s geographic area, and another RN from the agency confirmed no referral was received. The DNS acknowledged the resident should have had home care but was unsure about service start timing or agency coverage, and the SW confirmed that no home care services were provided and could not explain why a referral was not made or confirmed, contrary to the facility’s own transfer and discharge policy.
Failure to provide bed-hold notice at hospital transfer: A resident with Alzheimer’s disease, CHF, Afib, CKD, and agitation was transferred to the hospital after developing AMS, hypoxia, hypotension, and bradycardia while being treated for diverticulitis. The record did not show that the resident or representative received written bed-hold information explaining the duration of the policy, and staff interviews showed confusion about who was responsible for providing the notice.
The facility failed to provide timely notification to the State LTC Ombudsman when several residents with complex medical and behavioral conditions were discharged or planned for discharge. Although 30‑day Notices of Intent to Discharge were issued and discharge planning meetings were documented, the facility did not upload the required discharge notices to the Aging and Disability Services portal at the same time notices were given to residents and their representatives. In one case, a resident on an independent LOA later died in the ED, and no discharge notice was uploaded because staff considered it a transfer. For the other residents, uploads to the portal occurred days to over a month after the written discharge notices, and interviews with facility staff revealed they were unaware of a specific timeframe for notifying the ombudsman, contrary to CMS requirements and the facility’s own transfer/discharge policy.
Failure to notify the Ombudsman of resident hospital transfers. Four residents with diagnoses including Parkinson's disease, schizophrenia, diabetes, and pleural effusion were transferred or sent to the hospital, but the facility could not provide documentation that the Ombudsman was notified. The SW confirmed the monthly transfer-to-hospital forms were not sent for the reviewed period, and the DON was unaware the notifications were not being completed.
Failure to provide bed hold notices and monthly ombudsman discharge notifications. A resident with heart failure, dementia, and pneumonia was transferred to the hospital twice with severe respiratory decline, but the record did not show that the resident or representative received the bed hold policy at either transfer. Staff gave conflicting accounts about who was responsible for the notice. In addition, SW acknowledged ombudsman discharge reports were not sent monthly and were instead submitted in batches every few months.
The facility failed to provide required written notice of bed-hold rights to two residents or their responsible parties when they were transferred to the hospital for acute medical issues, including confusion after a fall and vomiting coffee-ground emesis with abdominal tenderness. Record reviews showed no documentation that bed-hold options were communicated at the time of hospitalization, despite a facility policy directing that such notices be given upon discharge to the hospital and maintained in the resident’s record. Interviews revealed that social workers did not issue bed-hold forms for hospital transfers and believed this was the responsibility of business office or admissions staff, while the Regional Business Office Manager acknowledged that the forms were missing and should have been provided.
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