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.
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.
Failure to Provide Required Transfer Notifications: The facility did not provide written transfer notices to three residents or their representatives when they were transferred to the hospital. The records lacked evidence that the notices included resident rights, the transfer location, the reason for transfer, and LTCO information, and the hospital transfer log did not document the transfers. Staff also confirmed the LTCO was not notified, and no discharge policy was provided.
Failure to provide written transfer notices and bed-hold information, and incomplete discharge documentation. The facility did not give residents or their representatives written notice or a bed-hold policy when residents were transferred to the hospital, and a discharged resident’s summary lacked a recapitulation of the stay, including med reconciliation. The discharged resident was alert and oriented to person and place, needed extensive help with ADLs, had skin issues, and had a urinary catheter with cloudy urine.
Failure to Provide Written Transfer Notification: A resident with severe sepsis, renal failure, and a below-the-knee amputation was found with acute changes including slurred speech, rapid breathing, and inability to communicate, then was sent to the hospital by ambulance. The EMR lacked evidence that written transfer notification was provided to the resident or his representative, and staff stated they were unaware of the requirement to notify the representative in writing of the transfer and reason.
Failure to provide written transfer notice and ombudsman notification. A resident with a femur fracture and CVA, who had intact cognition, had an unplanned discharge after the family requested the resident's meds and laundry be ready. The EMR lacked documentation of a written transfer/discharge notice to the resident or rep and lacked proof that the ombudsman was notified; an admin staff member could not locate either document and said another staff member was supposed to handle the ombudsman notifications but did not.
A resident with DM, stroke history, chronic respiratory failure, hypoxemia, and syncope was transferred to the hospital after reporting chest pain and shortness of air. Although she had intact cognition, the record lacked evidence that the facility provided written bed hold policy information to the resident or her representative at the time of transfer, and an administrative nurse verified the bed hold notice was missing.
A facility failed to provide written transfer/discharge notices with appeal rights to two residents who were sent to the hospital and failed to notify the ombudsman of the transfers. One resident with sepsis, UTI, and nephrostomy tubes had repeated hospital transfers for fever, pain, and worsening symptoms, and the EMR lacked bed-hold documentation after discharge to the hospital. A second resident was transferred by ambulance for chest pain radiating to the jaw and arms, but the record still lacked the required written notice and ombudsman notification.
The facility failed to notify the LTCO when a resident was transferred and admitted to the hospital. The resident’s record documented the hospital admission, but there was no evidence that LTCO notification was completed, and an admin staff member verified she had not notified them. The facility policy required a copy of the discharge notice be sent to an LTCO representative within 30 days.
Self-audit
Pick a level of detail and, optionally, what to focus on — then generate a survey-ready checklist distilled from the most recent citations.
Beta · AI-generated — for reference only, not professional advice. Verify against current CMS guidance before relying on it. Assisto accepts no responsibility for how this checklist is used.
Citations used to create this checklist
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release August 26, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.