Failure to Provide Written Discharge Notice: A cognitively intact resident with osteomyelitis, paraplegia, and chronic pain syndrome was discharged AMA, but the discharge notice in the record had no resident signature confirming receipt. The SSD and CNO initialed the form, and the SSD stated the resident did not receive a copy because he left and did not return, while the CEO was unsure whether written notice was provided.
Incomplete discharge transfer documentation: The facility failed to send complete hospital transfer paperwork for three residents during emergent transfers. Missing items included resident transfer forms, face sheets, care plan goals, physician H&Ps, advance directives, TARs, family/advocate notifications, verbal report with transport staff, and bed-hold notices. The CNO stated the checklist is used to show what was sent, but documents appeared to be missing for two residents, and the facility could not verify all required items were included for another resident.
Missing transfer documentation for two residents. One resident with COPD, dementia, and repeated falls was sent to the hospital for a hip issue, and staff could not find documentation showing all required transfer papers accompanied the resident. Another resident with anemia, HTN, and a duodenal ulcer had an acute event with a brief apnea episode and was transferred by EMS, but the emergent transfer form had no boxes checked to show which documents were sent.
A resident with acute cystitis without hematuria and COPD was transferred to the hospital, but the facility did not have documentation that a written bed-hold notice was provided to the resident or representative. The DON later stated she could not find any bed-hold data for the hospitalization, despite the facility policy requiring written notice within 24 hours or the next business day.
Incomplete Transfer Documentation: The facility failed to ensure a resident was transferred to the hospital with all required documentation. The record showed the resident, who had muscle weakness, dementia, and a left femur fracture, was sent with the POST, face sheet, and med list, but there was no documentation that care plan goals were provided to the receiving hospital. The DON stated additional transfer documents were typically sent, but neither the DON nor the CRN found evidence that the resident's care plan goals were included.
A resident with cerebral palsy and depressive disorder was transferred to the hospital, but the facility did not document completion of the required written bed hold notice for the resident or representative. The facility’s policy called for written bed hold notices at admission and again at transfer, and the SW confirmed the document was not completed.
The facility failed to complete required discharge processes for two residents transferred to a higher level of care. One resident with supplemental O2 dependence, chronic pain, and major depressive disorder was found unresponsive with low O2 saturation and respiratory distress, and another resident with Parkinson’s disease was discharged to the hospital for flap surgery. In both cases, there was no documentation that the State LTC Ombudsman was notified, and one record also lacked documentation of what discharge information was sent to the receiving facility.
The facility failed to document required transfer information, bed-hold notices, and Ombudsman notifications for two residents. One resident with a fracture and delirium was sent to the ED for low BP and low O2 sats, and another resident with weakness and recent sepsis was sent to the ED for cough, SOB, and low O2 sats; neither record showed the bed-hold policy was reviewed, and one record also lacked required transfer info such as care plan goals, med list, and advance directive.
Missing discharge and transfer documentation: A resident discharged home did not have documentation of receiving required discharge papers, including a med list and stay recapitulation. Another resident with schizoaffective disorder, bipolar type, dysphagia, and hypotension had dark emesis, was sent to the hospital by EMS, and the record did not show that the hospital received the resident’s current medical record, face sheet, MAR, advance directive if available, or POST.
Two residents who experienced emergent hospital transfers for issues including abnormal critical labs, uncontrollable pain, and SOB with low O2 saturation were not provided with required written bed-hold policies and transfer notices. One resident had severely impaired cognition, and another was cognitively intact and later died at the hospital. Progress notes documented the transfers and that contacts or family were notified, but there was no documentation that written notices addressing bed-hold, appeal rights, or ombudsman information were given, despite facility policies requiring such written information at admission and again at or shortly after transfer. The Administrator confirmed that bed-hold notices were not sent for these residents.
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