The facility failed to complete a discharge summary for a resident discharged home after managed care coverage ended. Survey review found only an incomplete recapitulation of stay, with no final status summary or medication reconciliation in the record, and the Market Lead Clinical Specialist confirmed the discharge summary had not been completed before discharge.
Failure to Provide Required Transfer, Discharge, and Bed Hold Notices: The facility did not provide written transfer/discharge notices or bed hold notices, including cost of care and appeal rights, for multiple residents transferred to the hospital. Records for several residents lacked evidence that the resident or resident representative received the required written notice, and the DON confirmed the missing documentation.
A resident with a planned discharge to independent living was discharged without evidence in the clinical record of a discharge summary, recapitulation of stay, or medication reconciliation. The care plan included referrals for PT, OT, HHA services, medication setup/management, and PSS support, and the DON confirmed the required discharge documentation could not be found.
A resident was transferred to an acute care hospital twice, but the facility did not provide the legal representative with the required written transfer/discharge notice or bed hold notice, including the cost of care and appeal rights. The BOM confirmed that these notices are not issued to resident representatives.
Incomplete Transfer/Discharge and Bed-Hold Notices: The facility failed to provide written transfer/discharge and bed-hold notices to resident representatives for multiple residents who were transferred to acute care. The notices reviewed were missing required appeal information, including contact details for the appeal entity and the State LTC Ombudsman, and lacked instructions for obtaining and completing an appeal form. Staff stated that transfer/discharge and bed-hold notices are not sent to resident representatives and that the bed-hold notice does not include appeal rights or contact numbers.
The facility failed to notify the Ombudsman of hospital transfers/discharges for two residents. Record review showed both residents were transferred and admitted to the hospital, and the RD of Clinical Services stated Ombudsman notifications were not sent for several months.
Failure to Provide Written Transfer/Discharge and Bed Hold Notices: The facility did not provide written transfer/discharge notices or bed hold notices to resident representatives for 4 sampled residents transferred to an acute hospital. Records showed the notices were not sent in writing, and the SS Mgr and an LSW confirmed the facility only sent a packet with the resident and notified the Ombudsman.
A resident was transferred and admitted to an acute hospital following a facility-initiated transfer/discharge, but the clinical record contained no written bed-hold notice or transfer/discharge notice to the resident or legal representative. This omission, affecting 1 of 3 sampled residents with such transfers, was confirmed by the DON during record review and interview.
Surveyors found that the facility did not provide required written bed-hold and transfer/discharge notices to two residents or their legal representatives when the facility initiated transfers to an acute hospital, and did not complete required discharge summaries for two discharged residents. In multiple instances, records lacked any documentation of bed-hold notices or transfer/discharge notices, and for discharged residents, there was no recapitulation of stay, no documented discharge instructions, no medication reconciliation, and no recorded follow-up appointments or therapy recommendations.
Failure to notify the Ombudsman of resident transfers/discharges and to provide a written transfer/discharge notice to a resident and legal representative. One resident was transferred home with services, but the LSW said Ombudsman notifications had not been sent for any transfers or discharges. Another resident was transferred to the hospital for respiratory distress, and the record showed no written notice was given to the resident or representative; the DON confirmed the notice was not provided.
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