Failure to complete bed-hold documentation and LTCO notification for two residents transferred to the hospital. One resident had an unplanned discharge AMA to a short-term hospital, and another had an unplanned hospital transfer with no bed hold completed and no LTCO notification reports available. Facility leadership stated the required bed-hold and ombudsman notices could not be produced, despite policy requiring timely LTCO notice and bed-hold notice during emergency transfers.
The facility failed to notify the LTC Ombudsman of hospital transfers and discharges for 3 residents. EHR and progress note review showed that two residents were admitted to the hospital and one resident was sent to the ER for surgical opinion and later discharged, but the Notice of Transfer Form did not include these events. Staff and the Administrator acknowledged the omissions, and the facility lacked a policy for the notifications.
A resident was discharged to another facility, and staff documented the transfer, report to the receiving facility, and paperwork being faxed. However, the EHR lacked the required discharge summary/recapitulation of stay, and staff interviews confirmed the summary was not completed even though the discharge checklist called for it.
Incomplete transfer documentation and missing required notices The facility did not thoroughly document hospital transfers for two residents, including missing details about the change in condition, current vitals, events before transfer, and forms sent with the resident. It also failed to give written transfer notices to two residents that included appeal rights, Ombudsman contact information, and contact information for agencies protecting residents with intellectual, developmental, mental, and related disabilities. In addition, the facility did not notify the Ombudsman after a resident was sent to the ED following a fall.
The facility failed to document bed-hold information for several residents sent to the hospital, including residents with MS, TBI, and severe cognitive impairment. In one case, staff contacted a resident’s representative after a change in condition, but there was no record that a bed hold was offered or discussed. The facility also lacked documentation that a resident, the resident’s representative, or the LTCSO received written advance notice of a planned discharge to another facility.
The facility failed to provide bed hold information for two residents who were hospitalized and failed to notify the ombudsman for one resident’s hospitalizations. One resident had ESRD, blindness, and breathing abnormalities with intact cognition, and the record lacked documentation of bed hold notices and ombudsman notification for multiple ER transfers. For another resident, the EHR documented several hospital leaves and transfers, but bed hold documentation was only found for one hospitalization, with no record for the others.
A resident with dementia, behavioral symptoms, and multiple psychotropic and cardiovascular medications was discharged to another nursing facility without a thorough or accurate discharge summary. The care plan contained a discharge planning focus but was never updated to reflect the actual discharge, and the EHR lacked documentation of discharge planning, the reason for discharge, or a recapitulation of stay, despite a family member stating they initiated the discharge due to dissatisfaction with care. The discharge instructions contained multiple medication discrepancies and omissions, including missing drugs, incorrect dosages, and absent administration frequencies, and several PRN constipation medications were not listed, contrary to the facility’s written discharge planning policy.
The facility failed to notify the LTC Ombudsman of a resident’s hospital transfers and discharges. The resident had COPD, HF, chronic hypoxic respiratory failure, and altered respiratory status, with multiple hospitalizations and returns to the facility. The Administrator believed Social Services had handled the notifications, but Social Services staff said they had not been trained correctly and could not provide documentation of Ombudsman notice. The facility’s transfer/discharge policy required the Social Services Director or designee to provide the required notices.
Incomplete Discharge Summary: The facility failed to complete a discharge summary for a resident with a BIMS of 15. The EHR showed the discharge summary lacked a recapitulation of stay, a final status summary, and reconciliation of pre- and post-discharge meds. The DON acknowledged the required discharge summary elements were not completed after the resident's discharge.
Failure to Notify Ombudsman of Resident Transfers: The facility did not notify the LTC Ombudsman of hospital transfers/discharges for two residents. One resident was discharged to an acute care hospital and was not expected to return, but was not listed on the monthly transfer/discharge notice. Another resident had severe RUQ pain, purplish lips, and pursed-lip breathing, was sent by ambulance to the ED, and later returned the same day, but was also omitted from the Ombudsman notice. The Administrator stated one notification was missed and said she did not know emergency transfers required notification if the resident was not admitted.
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