Failure to Provide Written Transfer Notice and Bed-Hold Information: A resident with anxiety, depression, schizophrenia, and intact cognition was sent to the ER by police after escalating behaviors and then transferred to an outside psych hospital. The record showed no written transfer notice with appeal rights or required contact information for the resident or guardian, and no evidence that bed-hold information was provided before transfer. Staff said they usually placed the bed-hold policy in the transfer packet but did not explain it to the resident or guardian, and the guardian reported receiving the policy only after the bed-hold period had already expired.
A resident with anemia post hemorrhage, COPD, and CHF left AMA, but the chart lacked a discharge summary/recapitulation of stay and other discharge documentation. The resident stated no discharge instructions, safety information, meds, or supplies were provided, and the Administrator confirmed the record did not document the resident’s condition upon discharge.
The facility failed to document a resident's transfer to the hospital and failed to issue a bed hold. The resident, who had a cerebral infarction with L-sided paralysis, left for an outpatient procedure, was found to have a UTI, and was admitted for IV antibiotics before the procedure. Staff stated the transfer details and bed hold should have been documented.
Failure to Provide Bed Hold Policy and Written Transfer Notice: The facility failed to document that 4 residents received the bed hold policy and written notice of transfer when they were sent to the hospital. Residents with no cognitive impairment and one resident with moderate cognitive impairment were transferred for issues including hematuria, abdominal distention/tenderness, and seizure-like activity, but records showed no proof the required paperwork was given to the resident or representative; the DON stated the documents were placed in an envelope with other paperwork and sent to hospital staff.
Failure to provide bed-hold notices and discharge summaries for two residents: Two Medicare Part A residents were transferred to the hospital, but the facility did not give written bed-hold notice to the resident or representative at transfer or within 24 hours. Both residents did not return, and no discharge summary/recapitulation of stay was completed after discharge. The ADM confirmed the notices were not provided because the residents were on Medicare Part A, and the SS Director stated the discharge paperwork was not completed because the discharges were unplanned.
Failure to provide required 30-day notice for an involuntary discharge. A resident with significant ADL dependence, incontinence, and repeated hospitalizations was not allowed to return after hospitalization. The POA and Ombudsman reported that the facility refused readmission without issuing the required written notice, and the administrator confirmed no 30-day notice had been sent despite the facility’s policy requiring written notification and appeal information.
A resident with multiple chronic conditions and moderate cognitive/functional needs was discharged with the wrong medications after staff mixed up discharge meds with another resident’s supply. The record showed the resident received several antihypertensives and other drugs that did not match her orders, while the other resident’s meds were not documented as having been properly reported to the resident, family, physician, or pharmacy. Staff interviews confirmed the mix-up occurred during discharge preparation and that the discharge process did not include proper physical medication reconciliation.
Failure to provide and document a Bed Hold Notice for a resident transferred to the hospital. The Administrator could not locate evidence that the notice was sent with the resident or reviewed with the POA, and the RN consultant confirmed it should have been provided and documented in the EMR. The Social Services Director stated no bed hold notification was communicated to the POA.
Failure to Provide Written Hospital Transfer Notifications: The facility did not document written notice to residents or their RP for hospital transfers/discharges for three residents reviewed. Records showed each resident had a change in condition and was transferred to the hospital for evaluation/treatment, but no written bed-hold or discharge notification was found. The DON stated she could not find the notices, and the SSD stated she was responsible for providing written discharge notifications and had not done so.
A resident was transferred to the hospital, but the facility did not document that a written bed-hold notice was provided to the resident or sent with him. The resident was cognitively impaired, and staff gave conflicting statements about whether bed-hold information is sent with residents or mailed to POAs. The health status note documented the transfer, but not the required bed-hold notice.
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