Failure to Provide Required Transfer and Discharge Notifications: The facility did not complete required Ombudsman notification or provide proper discharge notices for multiple residents during transfer and discharge events. One resident transferred to the hospital was omitted from the monthly Ombudsman report, another resident received a letter that lacked required discharge notice elements such as the reason for discharge and hearing/mediation rights, and a third resident who did not return from LOA had no documented discharge contacts, progress notes, or written notice with the required information.
A resident with stroke, depression, and dementia was transferred to the hospital after an unwitnessed fall, but the facility did not have evidence of a written notice of transfer provided to the resident or the RP. The chart showed the resident was sent out by ambulance for pain after the fall, and while staff documented that the family was aware and prepared, the DON could only produce a bed hold notice and no transfer notice.
Facility staff failed to ensure that a resident's representative received written transfer notice when a resident who lacked decision-making capacity was transferred to the hospital. The EHR contained no evidence of the notice, and the SW described the usual process of phone contact and mailing the notice, but the DON confirmed there was no documentation that the representative received it.
A resident was discharged home without home care, and the nurse’s note stated that all personal belongings and prescriptions were sent with the resident. However, review of the resident’s electronic and paper chart found no discharge instructions or prescriptions documented in the medical record, and the DON confirmed the omission.
A facility failed to provide written transfer notifications and bed hold policy information for two residents sent to the hospital. In one case, a resident’s RP was onsite during the transfer for chest pain, but the bed hold policy was not signed. In another case, the resident representative’s record did not show written notice for two hospital transfers, and the NHA confirmed the missing documentation.
Facility staff failed to properly document two residents’ discharges. For one resident, there was no nursing discharge note showing a safe and orderly discharge, and the discharge instructions lacked clear documentation of who provided them by phone. For another resident, a 30-day discharge notice was issued for nonpayment, but the reason was not documented in the progress note and the notice was not initially uploaded to the chart.
The facility failed to provide or maintain bed-hold policy documentation for three residents transferred to the hospital. EMAR review showed no bed-hold policy for residents sent out for hospitalization, and an interview with staff confirmed that the former BOM had handled distribution and that no bed-hold policies were provided in the BOM's absence.
The facility failed to provide required transfer notices for two residents who were sent to the hospital/ER. For one resident, the record showed a hospital transfer but no documentation that the resident or RP received the required notice, and for another resident transferred for generalized weakness and critically low sodium, the chart showed family notification but no written transfer notice. The DON confirmed that written transfer notices had not been provided.
A resident was discharged after rehab goals were met and insurance stopped payment, but the facility did not have a written transfer/discharge notice in the medical record. Staff said the resident received the insurer denial letter and was told discharge would occur if payment was not continued, but the required discharge notice with reason, effective date, location, and appeal rights was not documented in the chart.
Failure to Provide Written Bed Hold Notice: A resident was transferred to the ED, and while the RP was notified and understood the bed hold policy, the record did not show that a written bed hold notice was provided. The ADON stated that a bed hold notice and transfer notice are completed at transfer and sent to the RP if not present, but the facility could not produce documentation confirming the written notice was given.
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