A resident with metabolic encephalopathy was unplanned discharged to a hospital, but the facility did not provide written transfer notification to the resident or RR and did not include the resident on the monthly Ombudsman emergency transfer log. Staff interviews confirmed the facility was not using the transfer form to document the reason for hospitalization, and the ADM acknowledged that written communication and ombudsman reporting were not completed.
Failure to Provide Written Hospital Transfer Notices: The facility did not ensure written notice of hospital transfers, including the reason for transfer, was provided to residents or their RRs in a language and manner they could understand. Three residents were affected, including two with BIMS scores of 15 and one with a BIMS score of 9; their RRs reported receiving phone calls about the transfers but no written explanations. The DON confirmed there was no documentation of written transfer notices, and the Administrator stated staff were expected to follow the transfer notification policy.
Failure to Provide Written Transfer Notification: The facility did not ensure that two residents transferred to the hospital received written notice to the resident and/or representative stating the reason for transfer, the effective date, and the receiving location. One resident was sent for tube/drain replacement, and another was sent to the ER after hitting their head. The BOM stated the facility only sent the bed-hold notice and notified the ombudsman, and was unaware that the written transfer notice was required.
A resident with tracheostomy status, COPD, and acute/chronic respiratory failure, who required scheduled trach suctioning and nebulizer treatments, was discharged home without essential respiratory DME, specifically a suction machine and nebulizer. Although social services arranged some DME (hospital bed, wheelchair, bedside commode) and home health services, there was no evidence that suction or nebulizer equipment was ordered or delivery verified, despite facility policy requiring confirmation of all needed DME before discharge. After discharge, the resident lacked correct tracheostomy supplies at home, EMS was called to perform suctioning, and the resident was subsequently hospitalized. Interviews with the resident’s representative, social services, home health nurses, and the administrator confirmed that the suction machine was not included in the DME arrangements and that required equipment had not been ensured prior to discharge.
Failure to Notify Resident Representatives of Hospital Transfers and Bed-Hold Rights: Two residents were transferred to the hospital, but the facility did not notify the resident representative or provide the bed-hold policy in a timely manner. One resident had CHF and was sent out for elevated BNP and tachycardia, and the record showed no transfer notice or bed-hold information was sent. For another resident, the bed-hold agreement was completed days after the transfer. The AR clerk confirmed the omissions, and the Administrator stated transfer notifications and bed-hold letters should be sent for all hospital transfers.
The facility failed to provide written notice of a resident's hospital transfer to the resident's representative as required by policy. A resident was sent to the ER for severe abdominal pain and later had surgery for a bowel perforation, but Social Services confirmed no written transfer notice was mailed because the resident had been in the facility less than 24 hours. The resident was later readmitted with an abdominal wound and had a BIMS score of 7, indicating moderate cognitive impairment.
A resident was discharged home, but the facility did not send the required written notice to the Ombudsman or list the discharge on the Ombudsman transfer log. The Administrator confirmed the Ombudsman was not notified because the facility only notified for hospital discharges and was not aware of the regulatory changes. The resident’s record showed a diagnosis of fusion of the cervical spine.
Failure to notify the Ombudsman of a resident discharge. A resident admitted with cystitis and generalized muscle weakness was discharged home with HHC after therapy services, but the discharge was not reported on the facility’s Ombudsman transfer/discharge log. The SSD stated she did not send the notification and did not know it was required, and the facility had no policy for notifying the local or state Ombudsman of discharges to home.
Failure to Provide Plain-Language Transfer Reason: A resident was transferred to the ER for evaluation of AMS, but the transfer/discharge notice listed only "AMS" as the reason without explaining the specific basis in plain language for the responsible representative. The Unit Coordinator confirmed the abbreviation was used in error and was not written in a way the representative could understand.
Failure to Include Specific Transfer Reason in Transfer Notice: A resident with schizoaffective disorder and bipolar type was sent to the hospital twice for acute changes including low O2 sats, fever, disorientation, and difficulty swallowing meds. The written transfer notices sent to the resident's rep only stated that the resident transferred to the hospital/home with anticipated return and did not include the clinical reason for either transfer, and the BOM and Admin stated they were unaware the specific reason was required.
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