The facility failed to complete discharge summaries for two residents who were discharged from the LTC facility. One resident was transferred to the hospital after reporting intolerable abdominal pain and did not return, and another resident was discharged home with home care services. The DON confirmed that no discharge summaries were completed for either resident.
The facility failed to provide written transfer notices and bed hold policy information to residents and their representatives for multiple hospital transfers, and an LPN/social services designee confirmed the notices had not been given and the Ombudsman had not been notified. Residents involved had diagnoses including pneumonia, COPD, and rhabdomyolysis, and one resident was transferred for shortness of breath. The facility also lacked a proper discharge summary with a recapitulation of stay for a resident who died and was discharged to a mortuary.
The facility failed to ensure the Ombudsman was informed of all resident discharges and transfers. Record review showed that two residents had an emergency hospital transfer or discharge, but neither resident was included on the monthly transfer forms sent to the Ombudsman. The SSD confirmed the events were not reported as required.
Incomplete discharge summaries and missing Ombudsman notifications: The facility failed to complete required discharge documentation for three residents, including recapitulation of care, final status, med reconciliation, and post-discharge POC. Records also showed no evidence that the State LTC Ombudsman was notified of the residents’ discharges, and RN-B and the SSD confirmed the missing documentation and notifications.
A resident with a displaced R tibia fracture, fracture with routine healing, and HTN was transferred to the hospital for low BP, but the facility had no evidence that the resident or resident representative was given written notice of the reason for the transfer in a manner they could understand. The DON confirmed the lack of written notification at the time of transfer.
The facility failed to notify the State LTC Ombudsman of two resident discharges. Record review showed no evidence that discharge notifications were sent for either resident, and the Administrator confirmed there was no evidence of the required Ombudsman notifications.
Failure to provide written notice for hospital transfers. A resident was sent to the ER twice and placed on bed hold both times, but the EMR showed no evidence that the resident or representative received written notice explaining the reason for either transfer. The Administrator confirmed the required written notice was not provided.
Failure to Notify Ombudsman and Provide Bed-Hold Notice: The facility did not notify the state ombudsman of resident transfers in and out, and did not consistently provide written bed-hold information to a resident or the resident’s RP at the time of hospital transfer. Records showed multiple transfers, but no evidence that the required bed-hold notice was given during the transfers, and the BOM confirmed the notifications were not completed consistently.
A resident with PVD, DM, bilateral lower-extremity amputations, a sacral DTI, and moderately impaired cognition was transferred to the hospital, but the facility did not document the written reason for the transfer on the bed-hold/transfer notice. The Bed-Hold Notice lacked the transfer reason, and the facility could not locate a notice for one of the hospital discharges; the Administrator confirmed the omission.
A facility failed to complete a comprehensive discharge summary for one resident, including a recapitulation of care and medication reconciliation, after transfer to an acute care hospital. The facility also failed to notify the State Ombudsman of the discharges for two residents, including one discharged to the hospital and one discharged home; the DON and Social Services Director confirmed the omissions.
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