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.
Missing Transfer Documentation and Bed-Hold Information: Surveyors found that transfer paperwork for multiple residents did not include SBAR, comprehensive care plan goals, and, for one resident, the bed-hold policy. Staff reported sending limited documents such as the facesheet, MOLST, lab results, and orders, while the DON acknowledged that the required care plan and bed-hold information had not been included with the hospital transfer packets.
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.
The facility failed to notify the local Ombudsman of hospital transfers for two residents. One resident was hospitalized after an abnormal abdominal x-ray, and another resident was transferred to the hospital, but neither resident was included on the facility’s monthly admissions/discharges reports sent to the Ombudsman. The NHA stated the facility had been treating the reports as covering discharges and deaths only, not hospital transfers.
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 written bed hold notice upon hospital transfer for two residents reviewed. One resident with decision-making capacity was transferred for a GI bleed, but the EHR did not show written bed hold information was given at transfer; instead, the DON produced an unsigned, undated form and an email sent only to the resident’s emergency contact. Another resident, identified as their own responsible party, also had no record of receiving written bed hold information when transferred, and the only documentation provided was a later SWA note stating the SW contacted the resident about the bed hold policy.
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