Missing Written Transfer and Bed-Hold Notices: A resident with severe cognitive impairment and nonverbal status was transferred by ambulance to the ED for labored respirations and a change in LOC. The chart lacked evidence that written transfer and bed-hold notices were sent with the resident or provided to the resident’s representative, and staff stated these notices were not routinely sent with the resident.
A facility failed to notify the Ombudsman of a resident discharge. The resident completed skilled PT/OT, was independent with ADLs, had intact cognition, and was discharged to home/community with a plan to transfer to Assisted Living. The DON and LSW said they did not know the Ombudsman had to be informed of voluntary discharges, and the Ombudsman reported she had only been notified of hospital transfers, not all discharges and transfers as required by policy.
A resident admitted for rehab after a short hospital stay, with diagnoses including anemia, CAD, DM, and long-term anticoagulant use, left the facility AMA. The record showed the daughter was present, the PCP was updated, and a MAARC report was filed, but the discharge tracking log did not show that the Ombudsman was notified. The Admin confirmed the facility did not routinely report AMA discharges to the Ombudsman.
Failure to provide required bed-hold notice before hospital transfer. A resident with intact cognition and diagnoses including hemiplegia/hemiparesis, CHF, and COPD was transferred without documentation of bed-hold information in the progress notes. Staff said the charge nurse would ask the family about bed-hold, document verbal authorization, and social services would later mail the form, but no paperwork went to the hospital with the resident, despite policy requiring the resident and representative be informed of bed-hold rights and the policy accompany the resident for an ED transfer.
Failure to Notify Ombudsman of Resident Discharges: The facility did not send required OOLTC discharge notices for two cognitively intact residents. One resident was transferred to the hospital after a change in condition, and another left AMA, but neither discharge was documented on the facility’s ombudsman notification records. The DCS and administrator confirmed the missing notifications, and the facility policy required forwarding all discharge notices to the OOLTC and other required state agencies.
The facility failed to document a resident’s discharge and coordinate care with the receiving provider. The resident had diagnoses including endocarditis, anxiety, depression, bipolar disorder, and adjustment disorder, and was cognitively intact. The care plan lacked discharge planning, the chart lacked a discharge record and communication with the primary provider or receiving facility, and the DON stated she did not complete a discharge summary because she did not know where the resident went.
Failure to Notify Ombudsman of Facility Transfer: The facility failed to notify the LTC Ombudsman of a facility-initiated discharge for a resident who was transferred to a memory care center. The resident had diagnoses including acute cystitis, adult failure to thrive, TIA, cerebral infarction without residual deficits, and cognitive/awareness symptoms. The monthly transfer/discharge notice did not include the resident’s name, and the SSD stated the resident should have been on the faxed list and that it was human error.
A facility failed to provide written bed-hold/transfer notices for two residents sent to the hospital. One resident with multiple chronic conditions and dependence for care had repeated hospital transfers, but the record lacked written notice for later transfers. Another cognitively intact resident with diabetes, neurogenic bladder, and kidney disease was transferred for abdominal pain, and the chart lacked evidence of written bed-hold notice. Staff described a process that was often verbal or completed in the EMR without printing a copy for the resident or family, despite the facility policy requiring written notice and a signed copy in the record.
Failure to Provide Bed-Hold Notice at Transfer: The facility did not document that written bed-hold information, including the duration of the bed hold and reserve bed payment details, was provided to residents or their representatives when residents were transferred to the hospital. Four residents had hospital transfers, but EMRs lacked evidence of signed bed-hold forms or follow-up documentation; one resident stated he was never offered a bed-hold form, and another record noted a POA signature without showing what information was provided.
The facility failed to notify the ombudsman of a resident’s planned discharge back to the community. The resident completed therapy and discharged home with home health services, but the RN-A and SSD stated the ombudsman was only notified for emergency hospital discharges or AMA departures. The DON confirmed the facility policy required notification of all discharges.
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