Failure to provide transfer, bed hold, and ombudsman notifications: A resident had multiple unplanned hospital transfers with anticipated return, but the facility lacked documentation that the resident or representative received written transfer notices and bed hold information, including appeal rights and daily bed hold rates. The facility also lacked proof that the LTC ombudsman was notified of one hospital transfer, and staff stated the paper bed hold form was not scanned into the record.
Missing Discharge Recapitulation for A Resident: A resident with dementia, HF, and DM2 was discharged home with family, but the EMR lacked the required recapitulation of stay. The resident had moderately impaired cognition, needed assistance with toileting hygiene, showers, transfers, and personal hygiene setup, and had discharge planning needs involving family, SS, and VA-related placement/financial issues.
Failure to provide transfer, bed hold, and LTCO notifications: A resident was transferred to the hospital with return anticipated, but the facility could not produce the written transfer notice or bed hold policy for the resident or representative. SS and admin staff said they had been discussing who would send the Ombudsman and family notifications, but no notifications were provided, and admin staff verified the LTCO notice was not sent.
The facility failed to provide written transfer notices, bed-hold information, and LTCO notifications for three residents who were transferred to the hospital and later returned. Record review showed the residents had hospital discharge and re-entry events, but the facility could not produce documentation that the required notices were given. An admin staff member stated the transfer packet was supposed to be completed by nursing staff, but it had not been done.
The facility failed to notify the State Ombudsman of two residents’ hospital transfers. EMRs for two residents documented hospital admissions, but there was no evidence that the Ombudsman was notified, and the facility could not provide proof when asked. During interview, Social Services stated she had not made the notifications. The facility policy stated the State Ombudsman will be notified of all transfers and discharges.
Missing discharge recapitulation for a resident who left AMA. The resident had osteomyelitis, an acquired absence of the LLE below the knee, and type 2 DM, with intact cognition, a surgical wound, and a fall with injury. After stating he would leave to stay with family, he signed AMA paperwork and departed, but the EMR did not contain the required discharge recapitulation with the resident’s stay, treatment course, and final status.
A resident left the facility against medical advice, but the EMR lacked documentation that the LTC Ombudsman was notified in writing of the discharge. In a separate case, another resident was discharged to the community, but the record lacked a discharge summary with a recap of the stay and medication reconciliation; staff stated nursing and social services were responsible for discharge documentation and planning.
The facility failed to provide two residents and their representatives with written bed-hold notices that included the per diem rate to hold a bed, and failed to document transfer notices with appeal rights and state ombudsman information after hospital transfers. The records also lacked evidence that the LTC ombudsman was notified of the hospital transfers, and an admin staff member stated the facility had not been notifying the ombudsman for hospital transfers and that bed-hold forms had not been completed.
Failure to Notify Ombudsman of Resident Discharge: A resident with intact cognition was discharged to the community after requesting an earlier discharge and receiving a physician discharge order. The discharge was documented in the MDS and nursing record, but the monthly Ombudsman discharge/transfer log did not show written notification. Social service staff confirmed she did not notify the ombudsman for residents discharged to home or the community and only reported ER transfers.
Failure to provide a written bed hold policy at transfer. A resident with moderately impaired cognition became dizzy and unable to bear weight during a transfer, had severe abnormal vital signs, and was sent to the ER, later being admitted to the ICU for septic shock. The EMR lacked evidence that the bed hold policy was given at transfer, and staff stated the policy was missed and was not always sent when residents went to the ER.
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