Failure to Send Individual Discharge Notice to Ombudsman: A resident with MS, major depressive d/o, anxiety d/o, and tobacco use was transferred to the ED for evaluation, but the facility did not send the Ombudsman a copy of the resident’s individual transfer/discharge notice. Instead, the DSW faxed a weekly report listing generic discharge locations, which did not include specific addresses, and stated she was unaware that the Ombudsman office required the actual notices.
A resident with depression and anxiety, who was cognitively intact per a recent MDS, received a 30-day written Notice of Intent to Discharge stating that discharge to another LTC facility was necessary because the facility could not meet the resident’s needs. Although the facility’s policy required that such discharge notices be provided to the Office of the Long-Term Care Ombudsman so the resident could exercise appeal rights, there was no documentation that the notice was sent to the Ombudsman. The resident reported that the Ombudsman’s office told him they had not received the notice, and the Ombudsman confirmed in interview and email that no notice was received. The Assistant Administrator stated that he or a designee typically faxed such notices to the Ombudsman but could not produce any documentation showing this was done in this case.
A resident with a hx of SUD, including alcohol and heroin, was sent to the hospital after staff found illegal substances in the room. The facility later decided the resident could not return, but the discharge reason was left blank on the notice, no written discharge/appeal notice was sent to the resident at the hospital, and the Ombudsman did not receive notice. Staff and the Administrator acknowledged the communication to the hospital was verbal only.
A resident with Parkinson’s disease and recent acute delirium left AMA shortly after admission after the spouse was dissatisfied with aspects of the stay and requested medications be given before pharmacy delivery was available. Nursing notes show staff called the physician, but the resident left before the issue was resolved. The SW was not informed the resident had left and therefore did not notify the community PCP or elder-at-risk services as expected.
Failure to Provide Transfer/Discharge Notice and Bed Hold Policy: A resident with stomach and esophageal cancer and severe malnutrition was discharged to the hospital, but the record did not show that the resident or health care proxy received written transfer/discharge notice, the reasons for the move, appeal rights, or the facility's bed hold policy. An RN stated the required documents could not be located in the medical record and should have been provided upon discharge.
Missing Transfer and Bed-Hold Documentation for Hospitalized Residents: The facility failed to provide written transfer/discharge notices and bed-hold documentation for two residents who were sent to the hospital, and the forms were not kept in the medical record. Both residents had severe cognitive impairment, and staff interviews showed that nursing and social services were not consistently completing or filing the required paperwork, with forms often handled after the resident had already left the facility.
A resident with severe cognitive impairment and an invoked HCP was transferred to the hospital multiple times, but the facility did not document providing the HCP with the required transfer/discharge notices and bed hold policy for several of those transfers. One transfer also lacked a completed discharge/transfer evaluation, and staff stated the notices should have been given and documented each time the resident went out to the hospital.
The facility failed to provide transfer notices and bed hold information, and failed to notify the Ombudsman, for four residents who were sent to the hospital for evaluation. The affected residents included one who was transferred after a 911 call, one with clammy skin and garbled speech, one after an unwitnessed fall with hip pain and swelling, and one after a physical altercation and later another transfer for SOB and wheezing. Records showed no documented evidence that the required notices were given to the resident or representative or that the Ombudsman was notified.
A resident with encephalopathy, vascular dementia with behavioral disturbance, TIA, alcohol abuse, and wandering was transferred twice from the facility to the hospital, but the facility did not provide the required written notice of intent to transfer and/or discharge to the resident or the resident’s representative, nor did it send a copy of the notice to the State LTC Ombudsman as required by its own transfer/discharge policy. Review of the medical record showed no such documentation, and the Director of Social Services confirmed that no written notices or Ombudsman notifications could be produced.
Missing discharge summary documentation for a resident with Alzheimer's disease and COPD. The clinical record lacked a discharge note, discharge disposition, recapitulation of stay, physician discharge order, and discharge note from the MD or NP. The DON confirmed the discharge packet and nursing discharge documentation were not completed.
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