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 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.
A resident with cognitive impairment, diabetes, pressure ulcers, and an above-knee amputation was discharged without a safe discharge plan. Facility staff did not document review of the resident’s capacity and DPOA paperwork with the physician, did not honor the existing medical DPOA, and sent the resident home with insulin and other medications despite confirmed ADL dependence and transfer assistance needs. The resident was left at home without written discharge instructions and later required hospital care after failing the discharge.
A resident was transferred to the hospital and later denied readmission because the facility said it could not accommodate a cecostomy tube. The record showed no notice of transfer/discharge, no discharge summary, and no documentation that the resident or RP received the required appeal-rights information or the reason for the discharge decision.
Failure to provide transfer, bed-hold, and receiving-provider information: The facility did not document written transfer or bed-hold notices for multiple residents sent to the hospital, and transfer paperwork was incomplete. For residents with complex needs, including CHF, CKD, AFib, severe cognitive impairment, diabetes monitoring, pressure injuries, a urinary catheter, and suspected sepsis, the records lacked key details such as baseline status, diagnoses, meds and last doses, diet, labs, and other information needed by the receiving ED provider.
Failure to Notify Ombudsman of Resident Discharge: A resident was discharged from the facility, but the LTC Ombudsman was not notified. Record review and an email confirmation showed no discharge notice had been received, and the NHA stated the facility had never sent discharge notifications. The facility policy stated that the Ombudsman would be notified.
Failure to provide a written bed hold notice before a resident’s hospital transfer. A resident with metastatic cancer, weakness, HTN, and mild cognitive impairment was sent to the ED by ambulance after being evaluated and ordered for transfer. The record contained no bed hold form or proof the notice was given, and staff reported transfer packets were sometimes forgotten and that bed hold notices were not being provided or followed up on.
Failure to Provide Bed Hold Notice: A resident with a hip fracture was sent to the hospital after a fall, but the EMR did not show that a bed hold notice was provided to the resident or responsible party. The Resident Account Representative stated the facility does not give the bed hold policy to Medicaid residents when they go to the hospital, and the NHA acknowledged the notice had not been given, despite facility policy requiring bed hold information within 24 hours of a temporary absence.
Failure to provide a bed hold notice during a hospital transfer. A resident with impaired cognition, shortness of breath, hypertension, and assistance needs for bed mobility and transfers was sent to the hospital after family reported concern for a possible stroke. The transfer paperwork did not show that the bed hold form was provided to the resident or representative, and the DON could not locate the form. Facility staff stated the bed hold form should be given when a resident transfers to the hospital.
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