Failure to provide written transfer notices: The facility did not document that residents and/or their representatives were notified in writing of hospital transfers and the reasons for those transfers for seven sampled residents. Records showed multiple hospital transfers and returns, but no transfer notices were found. An LPN was unaware of an official transfer form, the SSD said he/she only mailed bed-hold notices, and the DON stated nurses were responsible for completing transfer sheets at the time of transfer.
Missing Bed-Hold and Appeal Information in Transfer/Discharge Notices: The facility failed to include required bed-hold amounts, appeal rights, and Ombudsmen/advocacy contact information in transfer and discharge paperwork for four residents who were sent to the hospital. Records for multiple hospital transfers showed missing daily bed-hold rates, and some forms also lacked a selected bed-hold preference. An LPN said the sending nurse completed the paperwork, and the Administrator stated staff should fill in all required blanks.
The facility failed to provide a bed hold policy and written transfer notice when three residents were sent to the hospital. One resident had low O2 saturation and an elevated RR before EMS transfer, another was hospitalized for dehydration, sepsis, and failure to thrive, and a third was sent out for suspected infection. The medical record lacked documentation that the residents’ representatives received the required notices, and the representatives said they did not receive them. Staff said the transfer packet was supposed to include these documents, but they were not always completed, and the DON said the initiating nurse was responsible for issuing them.
A facility failed to provide the bed-hold policy to two residents or their representatives at the time of hospital transfer or as soon as practicable, and failed to send discharge notices to the State LTC Ombudsman. Records for both residents showed no documentation that the bed-hold notice was given before discharge, and the Ombudsman reported not receiving discharge notices for months.
The facility failed to provide required written discharge notices, including appeal rights and bed-hold information, to three residents who were dependent on staff for ADLs and were cognitively intact or impaired. As part of a unit reconfiguration to free up rehab beds, residents were told by phone they had to move within a short timeframe and were discharged to other SNFs without documented 30‑day or emergency discharge notices. Families reported they were not offered in‑house room alternatives, felt they had no choice, were not informed of appeal rights, and did not receive written discharge notices. Social workers reported they were directed by an administrator to move residents to open rehab beds and believed written notices were unnecessary for SNF‑to‑SNF transfers, resulting in discharges that did not comply with required notification standards.
Surveyors found that the facility did not provide or document required bed-hold policy information when residents were transferred to the hospital, despite the Administrator stating that floor nurses were responsible for giving this information at the time of transfer. Review of records showed multiple transfers and discharges with no corresponding bed-hold documentation. In addition, the facility failed to send required copies of discharge notices to the State LTC Ombudsman, even though its written policy required Ombudsman notification for facility-initiated discharges, planned discharges and transfers, and discharges decided while a resident was hospitalized. The last documented Ombudsman notification and transfer log were several months old, and the facility lacked copies of discharge notices for more recent discharges.
Missing Written Transfer and Bed-Hold Notices: The facility did not ensure written transfer notices and bed-hold information were provided for three residents sent to the hospital. Records showed each resident had acute medical issues such as COPD, respiratory failure, pneumonia, sepsis, or dementia, and staff documented emergency transfers or hospital admissions, but there was no documentation that written notices were given or mailed to the resident or representative. Interviews showed staff typically called family and sent clinical paperwork, but were not aware of written transfer notices being provided.
Missing transfer, discharge, and bed-hold notifications: The facility failed to document, obtain signatures for, and send written transfer/discharge and bed-hold information to residents and/or their representatives, including appeal rights and Ombudsman contact information. Four residents who were transferred to the hospital had forms with no bed-hold choice, no daily room rate, no signature, and no proof that the information was provided in writing.
The facility failed to consistently provide written transfer/discharge notices and bed-hold information when four residents were sent to the hospital. Records showed transfers for cough and dyspnea, low blood sugar and lethargy, unsafe behaviors, and aggressive behaviors/agitation, but there was no evidence that the residents or their representatives received the required notices. Interviews confirmed nursing staff were responsible for the paperwork and that notices were being missed.
The facility did not follow its own bed-hold policy requiring written notice at the time of transfer for hospitalization. Record review showed that two residents who were discharged to the hospital did not have completed and signed bed-hold notices in their files, despite the policy requiring written notice specifying the bed-hold duration and return information and retention of a signed copy. In interviews, an LPN explained that the discharging nurse should fully complete the bed-hold form, including who was informed and the reason for discharge, and the Administrator stated he expected the notice to be given, completed, and signed before the resident left, but this did not occur for these transfers.
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