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.
A resident with schizophrenia, psychosis, anxiety, and other medical conditions left AMA after staff explained the risks and documented the departure on an AMA form signed by the resident and an LPN witness. Staff knew the resident had a court-appointed State Guardian but did not notify or involve the guardian before the resident left; the guardian was contacted only afterward and stated she had not been informed of the discharge, did not know where the resident went, and had no way to contact the resident. The facility’s own leadership stated the guardian should have been involved and signed the AMA form.
A resident was sent to the hospital after becoming unresponsive at dialysis, but the chart did not document the transfer, where she went, or the reason for the transfer. The record only showed an episode of emesis and later skilled charting with VS, mental status, and functional status. The DON confirmed the resident was not at baseline and had a change in condition, and stated an SBAR is normally documented, but none was found.
A resident was sent to the hospital, but the nursing record did not document the transfer/discharge, the reason for discharge, the discharge destination, or a bed-hold notice. The RN and DON stated that transfer paperwork and progress notes should include the resident’s condition, interventions, notifications, and required documents such as the face sheet, POLST, and bed-hold information.
A resident with chronic respiratory failure, venous insufficiency, and DM2 was discharged home without documented discharge planning, discharge assessment, or a recapitulation of stay. A CNA left the resident’s belongings and medical supplies on the porch, and the resident later reported no running water, no food, and no home health support. The DON and SSD confirmed no home health or safety screening was completed, and the MD stated he had ordered home health for the discharge.
Failure to confirm ordered equipment before transfer: A cognitively intact resident was discharged with CPAP and medication planning documented, but the hospital bed discussed in the care plan was not confirmed as delivered. Staff gave conflicting statements about whether the bed arrived, and the record contained no documentation confirming delivery before the resident left.
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