Two residents with complex medical conditions, including one with traumatic brain injury and another with ESRD on dialysis and paraplegia, were transferred to other SNFs within 24 hours without 30‑day discharge notices, physician discharge orders, or completed discharge recapitulations. In both cases, the ombudsman was not notified prior to the facility‑initiated transfers, and one resident reported being told the move was temporary for room work, while another was moved following a conflict involving family, law enforcement, and a roommate. The Social Services Director acknowledged not issuing 30‑day notices or contacting the ombudsman before arranging these discharges.
The facility failed to provide written notices of transfer, bed-hold practices, and appeal rights to responsible parties for two residents who were transferred to the hospital. Facility policies required written transfer/discharge notices with the reason for transfer, effective date, destination, explanation of appeal rights, and State appeal agency contact information, as well as written bed-hold information and retention of a signed copy in the medical record. For both residents—each severely cognitively impaired, dependent for all ADLs, and transferred for acute neurologic and respiratory concerns—documentation showed only that the responsible party was notified by phone, with no written notices in the EMR. The National Director of Risk Management reported that staff routinely called responsible parties but did not send written notifications and did not retain copies of bed-hold forms, and the Administrator stated he was unaware of the requirement to provide written transfer and bed-hold information upon hospital transfer.
Failure to provide required transfer and bed-hold notices: A resident with intact cognition, osteomyelitis, and an amputation was sent from a vascular appointment to the hospital and later returned to the facility. Staff reported that bed-hold forms were handled informally, the BOM was not notified of written transfer notices, and the ombudsman was not notified of hospital transfers. The Administrator was unsure about written transfer notices with appeal rights and ombudsman contact information, and the facility policy required written bed-hold information within 24 hours of an emergency transfer.
Surveyors found that the facility did not follow its own bed-hold policy for two residents with moderate cognitive impairment who were transferred to the hospital. The policy required that written information explaining bed-hold rights, state reserve bed payment rules, and the facility per diem rate be given to residents and their representatives before transfer. For one resident who was his own responsible party, there was no documentation that a written bed-hold notice was provided at the time of transfer or during the subsequent hospitalization. For another resident whose sister was listed as the primary contact, records lacked any confirmation that the bed-hold notice was reviewed with or signed by either the resident or the sister on the day of transfer, and the DON and Administrator confirmed that no such documentation existed.
A resident who was not cognitively intact was transferred to a hospital on two occasions without being provided a written bed hold notice or reason for transfer, as required by facility policy. The resident's representative confirmed not receiving the notice, and staff interviews revealed confusion over who was responsible for providing and documenting the bed hold information. No documentation was found in the resident's record to show that the required notice was given.
A resident was transferred to an acute care hospital without proper documentation of the transfer order, reason for transfer, or notification to the resident's representative. Required information such as the bed hold policy and appeal rights was not provided, and staff interviews confirmed that the facility did not follow its own transfer and discharge policy.
The facility did not provide required written transfer notices, including appeal rights and ombudsman contact information, to residents or their responsible parties when residents were transferred to the hospital. Bed hold notices were incomplete or missing, and notifications were not sent to the Ombudsman. Staff interviews confirmed that written notifications were not consistently provided, resulting in noncompliance with regulatory requirements.
A resident with hereditary and idiopathic neuropathy was transferred to the hospital twice for altered mental status, and the facility did not provide the resident or their representative with written notice specifying the daily bed-hold rate as required by policy. Staff interviews revealed inconsistent practices and lack of documentation regarding the notification process.
The facility did not provide required written transfer and bed hold notices to residents or their representatives during emergent hospital transfers. Multiple residents experienced acute events such as falls, respiratory distress, and unresponsiveness that led to hospital transfers, but there was no documentation of written notification in their records. Staff interviews confirmed a lack of awareness and practice regarding these notifications, and the facility only had forms for planned discharges, not for emergency transfers.
The facility did not provide written notification of hospital transfers to three residents or their representatives, as required by policy. Instead, transfer forms were sent with emergency personnel, and families were notified by phone, but no written notices were documented in the medical records. The residents involved had complex medical conditions and were transferred for issues such as falls, altered mental status, and chest pain.
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