A resident with cellulitis, chronic leg wounds, PVD, and an AKA was discharged after repeated grievances and behavioral issues, but the facility did not provide the required 30-day notice for a facility-initiated discharge. The record showed the resident was cognitively intact, wanted to remain in the facility, and had a history of homelessness, yet documentation did not show safe discharge planning, ability to manage wound care, or acceptance at the discharge address. The ED stated she did not issue a 30-day notice and did not believe it was required, even though the NP documented the discharge as facility-initiated.
Failure to Provide Transfer/Discharge Notice and Bed Hold Policy: Two residents were transferred to the hospital, but the clinical records lacked documentation that the Notice of Transfer or Discharge and Bed Hold Policy was provided to the resident or representative. One resident fell from a wheelchair and was sent to the ER, and another resident was hospitalized and later returned; the DHS stated the records did not show written notification.
The facility failed to ensure that two residents and/or their representatives received or signed transfer/discharge notices and bed hold documents when they were sent to outside psychiatric hospitals. One resident with alcohol dependence, anxiety, and TBI had multiple hospital transfers with missing signed notices, and one transfer lacked both the notice and bed hold policy. Another resident with dementia, insomnia, and HTN was sent to an inpatient psychiatric hospital, but the transfer/discharge notice and bed hold policy were not signed by the resident or representative. Staff stated these documents were given to EMTs, but could not confirm they were provided to the resident or representative.
Failure to Communicate Transfer Information During Hospitalization: A resident with severe cognitive impairment and multiple diagnoses had a sudden decline, was assessed, the MD was notified, and the resident was sent to the hospital and admitted to the ICU. The record lacked documentation of a physician order for transfer and lacked evidence that a condition report was called to the ER or EMS, including current VS, meds, and allergies, as required by the facility’s transfer/discharge policy.
Failure to Provide Bed Hold Notifications: The facility failed to provide written bed hold notification to two residents or their representatives when the residents were transferred to the hospital. One resident had CHF, DM2, and HTN and was sent out for abdominal pain with a distended abdomen; another resident with DM2 and CKD was sent out for critically low potassium. The DON could not locate documentation of the required bed hold notices, and the facility policy required written notice at transfer or within 24 hours for an emergency transfer.
A resident with severe cognitive impairment and significant psychiatric and behavioral diagnoses exhibited escalating verbal and physical aggression, leading to emergency transfer to a behavioral hospital. Although staff had previously discussed behavior concerns with the resident’s representative, the record shows no 30‑day notice of facility‑initiated discharge was issued, and no notice of transfer or discharge with appeal rights or attached bed‑hold policy was provided to the representative at the time of transfer or afterward. Documentation reflects that only the resident, not the representative, received the bed‑hold policy despite the resident’s confusion, and there were no subsequent facility notes of communication with the representative or the psychiatric facility. The Administrator and DON later acknowledged that the required 30‑day notice and transfer/discharge and bed‑hold notices were not provided, and the representative reported she never received any paperwork or appeal information.
Surveyors found that the facility failed to properly notify emergency contacts about the bed-hold policy for two residents who were transferred to the hospital. One cognitively intact resident with chronic kidney disease, diabetes, and a seizure disorder signed a bed-hold notification declining to hold the bed, but the resident’s emergency contact, who was also the durable power of attorney, was not notified when the resident became unresponsive and was sent to the hospital. Another resident with severe cognitive impairment, atrial fibrillation, lumbar fracture, wound dehiscence, and malnutrition was transferred to the hospital, and although the bed-hold policy was sent with EMTs and the emergency contact was informed of the transfer, there was no documentation that the emergency contact was informed of the bed-hold policy, even though the resident signed a form declining bed hold. No written facility policy on bed-hold notification was available for review.
Two residents with complex respiratory and cardiac conditions were transferred to the hospital—one for altered mental status and one after becoming unresponsive following administration of lorazepam and oxycodone-acetaminophen—without documented review of the required written transfer/discharge notice and bed-hold policy with them or their representatives. In one case, the record showed notification of the representative and hospital but no evidence that the notice and policy were reviewed; in the other, a form was completed and signed by the Social Services Director indicating the resident was unable to sign, yet there was no documentation that the information was reviewed with the resident or representative. Staff interviews and record review confirmed that the required written notification process, as outlined in facility policy, was not documented for these hospital transfers.
Failure to Provide Transfer/Discharge Notice and Bed Hold Policy: A resident with liver cancer, altered mental status, and malnutrition was sent to the ER after being found lethargic and difficult to rouse, then admitted to the hospital. The record lacked documentation that the resident or representative received written transfer/discharge notice and the bed hold policy, and the notice provided during survey did not include the bed hold policy.
A resident with COPD, dementia, a legal guardian, and an active DNR order was transferred to the hospital for shortness of breath, but the transfer form listed CPR status and identified the wrong resident representative as notified. The guardian said the facility called the nephew instead of her, and hospital staff later told her they had been informed the resident was full code. No copy of the transfer packet sent with the resident was provided.
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