Missing Discharge Summaries: The facility failed to ensure required discharge documentation, including the recapitulation of stay, was completed for 3 discharged residents. Records contained transfer/discharge reports and/or signed discharge instruction forms, but no recapitulation of stay was located. The Administrator stated the EHR was not configured to generate the document, and the DON confirmed there was no policy for discharge documentation.
Failure to notify the State Ombudsman of a resident hospital transfer. A resident with AFib, cardiomyopathy, and CHF was hospitalized for cellulitis requiring IV meds and then returned to the facility. The Administrator confirmed the facility had no Ombudsman notification records for the month, had not submitted the required notifications for several months, and stated there was no policy for Ombudsman notifications.
The facility failed to provide bed hold notices for two residents reviewed for hospitalizations. One resident with insomnia, muscle weakness, and heart failure fell and was transferred to the hospital, and another resident with heart failure, anxiety disorder, and depression was also hospitalized; both had intact cognition by BIMS. The clinical record lacked documentation that bed hold information was given to the resident or representative at the time of transfer, and the DON stated she could not locate the notices while the facility policy required written notice at transfer.
Failure to notify the LTC Ombudsman of a resident transfer occurred when a resident with cancer, HTN, DM, depression, and moderately impaired cognition was sent to the hospital and later readmitted. The resident’s name was missing from the ombudsman transfer notice and the admission/discharge report, and the SW stated she believed notification was only needed for discharge to the community.
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 complete required transfer-related documentation for several residents, including Ombudsman notification, written bed hold notices, and records of resident disposition and belongings. Records for multiple residents showed hospital transfers or returns, but the EHR lacked the required written orientation and transfer information, and staff reported that bed hold notices could not be found. An email also indicated the facility did not have an Ombudsman policy.
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.
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