A resident with intact cognition was given a discharge notice stating he no longer needed the facility’s services, but the notice did not include accurate required appeal information. The form lacked correct contact details for the state appeal entity and ombudsman, and the resident later appealed with ombudsman help; the appeal was upheld because the notice was incorrectly completed.
Failure to provide bed-hold and transfer notices affected two residents. One resident with chest pain and intact cognition was sent to the hospital without documentation of receiving a Bed Hold or Transfer Notice, and a second resident with severe cognitive impairment was transferred to the ER after an unwitnessed fall without a bed-hold/transfer notice; the family representative reported not receiving notice by mail. Staff interviews showed inconsistent understanding of how the notice was to be issued and mailed.
A facility failed to provide required written bed-hold and transfer notices to three residents and their representatives when the residents were sent to the ER by ambulance. The notices were not given before transfer or upon return and did not include the required reason, date, location, appeal rights, or Ombudsman contact information; family representatives said they were only called about the transfers and did not receive the forms by hand delivery or mail.
Failure to Provide Written Transfer and Bed Hold Notices: The facility did not provide written transfer notices to the representatives of two residents who were sent to the ED by EMS after acute events. One resident had Parkinson’s disease, repeated falls, and moderate cognitive impairment after a fractured femur was identified; the other had Alzheimer’s disease, dementia, anxiety, and severe cognitive impairment after a fall. Records contained no transfer or bed hold documentation, and staff could not confirm that the required written notices were mailed to the representatives.
A resident was transferred to the hospital without written notice of the transfer, the reason for the transfer, or the bed hold policy, and no copy of the notice was kept in the EMR. The record also lacked documentation of the transfer/discharge and the facility did not notify the State LTC Ombudsman. Staff interviews showed the facility relied on verbal notification and only provided transfer and bed hold forms if requested.
Failure to Provide Written Transfer/Discharge Notice: The facility did not provide a resident’s representative with written notice of hospital transfers or the reasons for the moves, and the record lacked Transfer/Discharge Notices for either event. The resident had cerebral palsy, malnutrition, and epilepsy, and was rarely or never understood per MDS. Staff stated the family was informed verbally, while the BOM handled bed-hold notices and was unsure who was responsible for the written transfer/discharge notice.
Failure to Provide Transfer Notices to Resident Representatives: The facility did not provide the required written transfer/bed-hold notice to the representatives of two residents who were sent to the hospital. One resident had severe cognitive impairment with dx including IDD, DM2, and epilepsy, and the other had moderate cognitive impairment with dx including pneumonia, subdural hemorrhage, and HTN. In both cases, the transfer forms had blank mailing documentation, and the representatives stated they never received the paperwork.
Failure to Notify Family of Hospital Transfer and Required Written Notice A resident with severe cognitive impairment and multiple chronic diagnoses was sent to the ER, but the facility did not notify the resident's representative or provide written notice of the transfer, the reason, location, or appeal rights. A grievance log noted the family was not notified, and interviews with the family member, MDS Coordinator, DON, and Administrator confirmed the representative was not called or given a bed-hold notice.
Failure to Provide Written Transfer and Bed-Hold Notices: A resident with hip fracture, Alzheimer's disease, and BPH was transferred to the hospital for hematuria, but the facility did not provide the resident's POA with a written transfer notice, appeal rights, state agency contact information, or a written bed-hold notice. The packet sent with the resident contained clinical information only, and the Administrator stated the facility called family but did not send written notice.
Failure to provide written transfer and bed hold notices: Two residents with intact cognition and significant medical histories, including dementia, CKD, and acute kidney failure, were transferred to the hospital, but the facility did not consistently notify the resident’s representative in writing of the bed hold notice, transfer/discharge, or reasons for the move in a language and manner they could understand. Staff interviews showed the BOM handled notices inconsistently, the DON said nursing did not complete the notifications, and the Administrator expected the notices to be sent and documented.
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