A resident with multiple diagnoses, including CVA-related dysarthria, paraplegia, adult failure to thrive, and MDD, was transferred to another SNF after repeated behaviors. The record showed the transfer was facility-initiated, but there was no documented prior discussion, no 30-day discharge notice, and no notification to the Ombudsman, despite the resident having a BIMS score of 14 and little to no cognitive impairment.
Failure to Provide Transfer, Discharge, and Bed-Hold Notifications: The facility failed to communicate transfer information to the hospital and failed to provide written notice to a resident and resident representative about the reason for hospital transfer/discharge and the bed-hold policy, including reserve bed payment. The resident had CHF, atrial fibrillation, a cardiac pacemaker, anxiety disorder, and severe cognitive impairment, and was sent to the hospital for respiratory distress. The DON confirmed the required notifications were not issued, and the facility policy required transfer/discharge documentation and communication to the receiving provider.
Failure to Provide Transfer, Bed-Hold, and Discharge Documentation: The facility did not provide written transfer/discharge notices or bed-hold information to several residents or their representatives when residents were sent to the hospital, despite policies requiring notice of the reason for transfer, appeal rights, and Ombudsman contact information. The DON stated the facility had been sending an eInteract transfer summary instead. The facility also failed to complete required discharge documentation for a resident discharged AMA, including medication reconciliation, final status summary, recapitulation of stay, and Ombudsman notification.
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 written bed hold and transfer notices for two residents. One resident with colon cancer, anemia, ileostomy, diverticulitis, and psychiatric diagnoses was transferred to the hospital, and another resident with COPD and weakness was discharged, but neither record showed a written notice explaining the transfer/discharge or the bed hold policy. The BOM confirmed no bed hold notice was found, an LPN said residents should receive the policy, and the Ombudsman reported no notification for either resident.
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.
Failure to Provide Transfer and Bed-Hold Notices: The facility did not provide written transfer notices or bed-hold information to residents or their RRs after emergent hospital transfers for four residents. Records showed missing eInteract transfer forms and no documentation that the required notice, appeal rights, or bed-hold details were sent with the resident, communicated to the hospital, or provided to the RP/RR. The DON, Administrator, and FC confirmed the notices were not completed or sent.
Failure to Provide Transfer and Bed-Hold Notices After Hospital Transfers: The facility did not provide required written transfer/discharge notices or bed-hold notices to residents or their RRs after emergent hospital transfers. Records for four residents showed repeated ER/hospital send-outs and returns, with diagnoses including paraplegia, metabolic encephalopathy, post-stroke hemiplegia/hemiparesis, and spastic hemiplegia with dysphagia. The BOM confirmed the notices were not given when residents were transferred out to the hospital.
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