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.
A resident was transferred emergently to the hospital for a decline in health and abnormal behaviors, and the facility did not provide the resident or representative with a transfer/discharge notice or a bed-hold notice. Staff stated these notices would be expected for any resident sent out of the facility, but the EMR did not show they were completed.
The facility failed to maintain evidence of Ombudsman notification for a resident’s hospital transfer. Staff said transfer and discharge notices were handled verbally and informally, and no documentation was available for the resident’s acute-care transfer. The facility policy required evidence that notice was sent to the Ombudsman and allowed emergency transfer notices to be provided when practicable.
Incomplete Transfer Notice: A resident was transferred to the hospital, but the written transfer notice was missing the specific reason for the transfer. The resident did not recall receiving paperwork before the hospital transfer, and an LPN who signed the form could not explain why the reason section was left blank. Facility policy required the notice to include the specific reason and basis for transfer.
A quadriplegic resident was transferred to another facility without being provided with a wheelchair, despite reliance on it for mobility, and arrived at the receiving facility without one. Additionally, the facility did not document the discharge in the medical record, omitting key information about the transfer and the resident's care.
Self-audit
Pick a level of detail and, optionally, what to focus on — then generate a survey-ready checklist distilled from the most recent citations.
Beta · AI-generated — for reference only, not professional advice. Verify against current CMS guidance before relying on it. Assisto accepts no responsibility for how this checklist is used.
Citations used to create this checklist
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release August 26, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.