The facility failed to notify the LTC Ombudsman of transfers/discharges for two residents. One resident with cardiomegaly, schizophrenia, and dementia was sent to the hospital after increased agitation, paranoia, and combativeness, and another resident was discharged after requesting discharge; the records did not show the required Ombudsman notification, and the facility could not provide the transfer/discharge lists requested during survey.
The facility failed to notify the LTC Ombudsman of transfers and discharges for three residents. Two residents were transferred to the hospital and one resident had a lateral transfer to another facility, but the Ombudsman notification records did not include these discharges. The Social Services coordinator stated she was responsible for the notifications but did not know all discharges had to be reported, and the facility policy did not address notifying the Ombudsman.
A resident with dysphagia, COPD, emphysema, malnutrition, a stage 2 sacral pressure ulcer, urinary retention with a Foley, and orders for HH, wound care, PT/OT, PEG supplies, oxygen, and a wheelchair had an incomplete discharge summary. The record omitted key discharge details such as the primary provider, follow-up appointments, pharmacy info, home care agencies, and needed DME, and it lacked nursing documentation of the exact discharge date and related discharge notes.
Failure to provide a bed hold notice before transfer. A resident with urinary retention and intact cognition was sent to the ER after new orders were received, but the record showed no documentation that a bed hold was provided. The DON confirmed the absence of both a progress note and an uploaded copy of the bed hold, and an LPN did not recall giving the notice before the hospital transfer.
A resident was transferred to the hospital for catheter-related complications, but the facility did not document providing the resident or representative with the bed hold policy at the time of transfer. Although staff later called the family, the family said bed hold information was not given, and the NHA confirmed the resident should have received written bed hold notice before the hospital transfer.
Failure to Notify Ombudsman of Transfers and Discharges: The facility did not send required Ombudsman notices for transfers, discharges, or admissions for three years. Two residents reviewed had hospital transfers, and the social service designee had not been sending the required notifications. Corporate and facility leadership confirmed the omission, and the facility’s transfer/discharge guidelines stated that a copy of the discharge notice is sent to the State Office of LTC Ombudsman.
The facility failed to provide a bed hold notice to one resident transferred to the hospital and failed to send written transfer notices to the Ombudsman for two residents sent out for changes in condition. The NHA stated the facility was not sending the Ombudsman a discharge list, and staff reported that residents or their representatives were not given a bed hold notice when transferred.
Failure to Provide Written Transfer Notice: A cognitively intact resident was transferred to the hospital for shortness of breath, and the facility gave paperwork to ambulance staff and explained the bed hold policy to the family, but did not provide the resident with a written transfer notice. The DON stated the transfer form in use did not include appeal rights or the State LTC Ombudsman contact information, and acknowledged the facility had a written transfer form that was not given to the resident.
Failure to Provide Written Transfer and Bed Hold Notifications: The facility did not document that two residents or their responsible parties were given written notice of the reason for hospital transfers and/or the bed hold policy. One resident had COPD, chronic respiratory failure with hypoxia, CHF, and moderate cognitive impairment, with multiple hospitalizations and no record of written transfer or bed hold notices. Another resident was cognitively intact, was transferred to the ER after reporting blood in her brief and constipation, and the EMR showed only a phone call to the spouse; there was no written transfer notice and the bed hold form sent was blank.
Failure to Document Transfer Information Sent to Hospital: The facility failed to document that required transfer information was communicated to the receiving hospital for four residents sent to the ED. The EMR did not show practitioner contact information, resident representative details, advance directive information, care plan goals, discharge summary, or special instructions for ongoing care, and the DON stated the facility does not document what is given to the hospital during transfers.
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