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.
Failure to provide written transfer, discharge, and bed-hold notices: The facility did not give 3 residents and their representatives the required written notices for emergency transfers/discharges, including the reason for the move, transfer date and location, appeal rights, and LTC Ombudsman contact information. The EMR had no transfer/discharge or bed-hold notices for any of the residents, and family members reported they were only called and told verbally about the transfers.
Failure to provide bed hold notifications for two residents during emergent hospital transfers. The facility policy required a written bed hold notice to be given to the resident or representative within 24 hours of an emergency transfer, but there was no documentation in the EMR or paper chart for either resident, and the facility could not produce copies of the notices. Interviews showed inconsistent understanding among staff about whether the floor nurses or the business office were responsible, while the DON stated floor nurses were expected to ensure the resident or representative received the form.
Failure to Provide Written Transfer/Discharge and Bed Hold Notices: The facility did not document that it gave written notice to residents and/or their representatives explaining the reason for hospital transfer/discharge or the bed hold policy, including reserve bed payment, and did not send copies to the ombudsman for 3 sampled residents. The affected residents had diagnoses including Parkinson’s disease, COPD, CHF, respiratory failure, dementia, and stroke-related deficits, and were sent to the hospital for issues such as abdominal pain, altered mental status, decreased urine output, and possible stroke. Staff described phone calls and packet information, but proof of the required written notices was not provided.
A resident with multiple chronic conditions was transferred to the hospital for acute symptoms, and while the facility verbally notified the resident's representative and sent documentation with the resident and to the Ombudsman, it failed to provide the required written notification of the transfer and bed-hold policy directly to the representative.
A resident with multiple chronic conditions was transferred to the hospital for sepsis related to kidney stones, but neither the resident nor their representative received the required written notification regarding the transfer, bed hold policy, or appeal rights. Facility staff confirmed that only verbal communication was provided and that written notices were not sent to the representative or the Ombudsman.
A resident with multiple medical conditions was discharged home without receiving the required written notice of discharge, and the Office of the State Long Term Care Ombudsman was not notified. The facility could not provide documentation or policies related to the discharge, and leadership interviews confirmed the absence of the necessary notifications in this case.
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