Failure to notify the Ombudsman of resident transfers and discharges. The facility did not document or send required Ombudsman notices for multiple residents who were transferred to the ED/hospital or discharged, including one resident who left AMA and another discharged home with HHC. Records showed transfers related to catheter complications, cystitis, GI symptoms with ostomy issues, weakness after a fall-like event, and rectal bleeding, while the SSD, DON, and Administrator stated they were unaware of the current reporting process and had not been sending the required notices.
Facility staff failed to provide written bed hold policy information to residents or their representatives when residents were transferred to the hospital. Record review showed multiple residents had hospital transfers, including some who returned and some who did not, but their charts lacked documentation that the bed hold policy was given at discharge. The administrator acknowledged the deficiency, while the DON stated he/she had been told a bed hold signed on admission did not need to be provided again on transfers.
The facility failed to consistently send transfer and discharge notices to the Ombudsman for multiple resident discharges. The Ombudsman reported not receiving the notifications consistently, the SSD said he had not sent the documentation and was unsure what the prior SSD had done, and the Administrator said she expected the SSD to handle the required notices. The facility also had not had a dependable SSD for several months.
Failure to provide written transfer notices and bed-hold information: The facility did not document that written transfer/discharge notices or bed-hold policies with the daily rate amount were given to several residents or their representatives when residents were sent to the hospital, including emergency ER transfers. Facility leaders stated staff were expected to complete transfer/discharge notices for all hospital transfers and include the bed-hold rate amount, but the rate was not included on the bed-hold policy.
Incomplete bed-hold documentation was found for four residents who were transferred to the hospital. Their Bed-Hold forms did not include the daily bed hold rate, even though the facility policy required written notice of the bed-hold option and accompanying paperwork during hospitalization or therapeutic leave. The Administrator and SSD stated the nurse was responsible for entering the rate and the SSD for ensuring it was completed, but the forms remained incomplete.
Failure to Notify Ombudsman of Resident Discharges: The facility did not send the Ombudsman copies of resident discharge notices for multiple months, despite policy requiring notice for transfers and discharges. The Ombudsman reported not receiving any notices, while the SSD and Social Service Director each stated they had not been sending them and believed another staff member was responsible.
The facility failed to provide written transfer notices and bed hold information, including the daily rate, to residents and/or their reps for multiple hospital transfers, and failed to notify the ombudsman. Records for several residents showed hospital transfers and returns, but no documentation of the required written notices or bed hold details. The Ombudsman said transfer notices were not being submitted through the new system, and the Administrator said there was no proof the notices had been sent.
Failure to provide written transfer and bed hold notices: Multiple residents were transferred to the hospital, but the transfer/discharge forms did not include the reason for transfer and the bed hold notices did not include the daily rate. For one resident, there was also no documentation that the resident or representative was informed in writing of the transfer. Staff interviews showed inconsistent understanding of Bed Hold Notices, and the facility had no policy for transfer/discharge or bed hold notices.
Failure to Provide Bed-Hold Notices at Transfer: Facility staff did not provide written bed-hold information to the resident and/or representative when three residents were transferred to the hospital. Records for one resident, one resident with multiple hospital transfers, and one resident who later remained in the hospital on hospice lacked documentation that the required notice was issued. Interviews showed nursing staff and the SSD were expected to complete and follow up on the notices, but the omission was not known at the time.
Incomplete bed-hold and transfer/discharge notices were found for four residents after hospital transfers. The forms did not document the resident or rep election to hold the bed, the daily bed-hold rate, or signatures, and the transfer/discharge notices did not state the reason for transfer or include required protection-and-advocacy agency contact information. The SSD and Administrator said they were unaware of these documentation requirements.
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