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.
The facility failed to give a resident or the resident's representative written notice of the bed hold policy when the resident was transferred to the hospital, and it also failed to send all pertinent information to the receiving hospital. An staff member stated the notice and hospital report were not provided, even though facility policy required them.
The facility did not consistently provide required written notifications of resident transfers and discharges to the local Ombudsman, as mandated by policy. Several residents were transferred to hospitals or discharged, but the responsible staff member failed to send or retain copies of the notifications, and the Ombudsman reported not receiving them for an extended period.
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