Failure to provide written transfer and bed-hold notice: A resident with dementia and a BIMS score indicating mild to moderate impairment was found on the floor, sent to the hospital, and admitted. The resident received verbal notice of transfer, but the POA/rep was not sent the required written Notice of Transfer/Discharge with the reason for transfer and bed-hold information; staff said the form probably was not mailed because the responsible staff member was off work.
Failure to provide written transfer and bed hold notice: The facility did not notify a resident, the resident's representative, or the local Ombudsman in writing of the reason for a facility-initiated transfer or the bed hold information. Staff stated the nurse initiates the bed hold in the EMR, but residents do not receive a copy and no signature is obtained. The resident's EMR did not contain the required Bed Hold and Notice of Transfer form, and the facility did not provide the requested documentation.
The facility failed to document required transfer/discharge information for two residents and did not notify the Ombudsman’s office of all resident transfers/discharges. Staff said nurses completed LOA/bed-hold forms but did not chart the LOA or transfer in the EHR, and no follow-up documentation was done unless the resident returned. One resident remained in a hospital after transfer with no documentation of an indefinite transfer or bed hold, while another resident had a trial home LOA and discharge without the required discharge documentation.
Failure to Provide Transfer and Bed Hold Notices: The facility did not consistently provide or complete written transfer/discharge notices and bed hold information for multiple residents. Records showed missing or incomplete documentation for a resident transferred to the hospital with cough and dyspnea, and for another resident whose transfer forms lacked staff names, signatures, and resident/responsible party identification. Staff stated nurses were responsible for completing the forms, but the required notices were not present in the record.
Failure to Provide Bed-Hold and Transfer/Discharge Notice: A resident was sent to the hospital by ambulance after the family requested transfer, but the EMR did not show that the resident or representative received the required written bed-hold or transfer/discharge notice before departure. Staff said the notices are usually reviewed at admission and again before discharge, but that did not occur because the resident was transferred to an out-of-town hospital; the facility later had unsigned notice forms dated for the discharge.
A facility failed to document required discharge information for a resident who was transferred out by family. The chart only noted that the resident left via transport, belongings were packed, and meds were sent; it did not include a discharge planning assessment, discharge summary, destination, or communication to the receiving facility, despite the facility policy requiring pertinent care-related information and a discharge summary.
The facility failed to give written transfer notices to residents and/or their representatives when two residents were sent to the hospital, including the reason for transfer and bed-hold information. One resident was transferred for evaluation and treatment of worsening wounds, and the representative said no bed-hold paperwork was provided. The facility also did not send the hospital transfer notices to the local Ombudsman for the two residents, and staff interviews showed confusion about who was responsible for reporting hospitalized residents.
Failure to notify the Ombudsman of a resident AMA discharge. A resident left the facility after stating it was his choice to go, and staff documented that he did not return and was later considered AMA after being noted as AOx4 and independent with decision making. The record included an AMA form, but the resident signature line was blank, and the facility could not produce evidence that the Ombudsman was notified as required by policy.
A resident was transferred to a hospital and did not return, yet the facility failed to provide or document the required written transfer and bed-hold notices. Staff reported that residents transferring out are supposed to sign transfer and bed-hold forms, with nurses completing and assisting with signatures as needed, but could not confirm that this occurred for the resident involved. Review of facility policies showed that written notices explaining the reason, effective date, and destination of a transfer, as well as bed-hold notices given in advance and at the time of transfer or within 24 hours for emergencies, must be provided and kept in the clinical record; however, no such notices were found for this resident, and a facility document indicated there was no bed hold for the transfer.
Failure to Provide Written Transfer Notice: The facility did not provide the resident's representative with a written notice explaining the reason for a hospital transfer for a resident sent out for stroke-like symptoms. The rep stated no transfer letter was received, and record review found no documentation of the notice in the resident's EMR.
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