Missing Transfer and Bed-Hold Notifications: Three residents were transferred to the hospital for altered mental status, nausea/vomiting, and dehydration, but the facility did not complete written transfer notices or provide written notice to the residents and their representatives in a language and manner they understand. Bed-hold notices were also incomplete or absent, with no documentation of the number of days the bed would be held or the cost after the held days. The ADON and DON confirmed the missing documentation.
A resident was sent to the hospital by EMS after a fall in the bathroom with pain, swelling, and redness noted on assessment. The EHR did not show that staff provided the required written transfer notice or bed-hold notification to the resident or representative, and there was no documentation that the State LTC Ombudsman was notified; the DON confirmed these notices were not provided.
A resident was transferred to the hospital for AMS, and although staff documented a written transfer notice and bed hold notice, the facility did not send a copy of the transfer notice to the Ombudsman. An RN said nursing staff complete the notice at transfer but was unsure if it is sent, and the Ombudsman stated she does not receive copies of the written transfer notices.
Missing discharge, transfer, and bed-hold documentation: The facility failed to provide required transfer/discharge notices for three residents, including appeal rights and Ombudsman contact information, and failed to document a bed-hold notice for one resident’s hospital transfer. For two residents, the medical record also lacked discharge summaries with recapitulation of stay, resident status, medication reconciliation, and follow-up information. The DON confirmed the missing notices and documentation, and stated that copies of discharge or transfer notices were not sent to the Ombudsman.
Surveyors found that the facility did not provide required written transfer and bed-hold notices when several residents were sent to the hospital for events such as falls with injury, unresponsiveness, and episodes of nausea, vomiting, and bleeding. Medical records lacked written transfer notices and bed-hold notifications, and the transfer information that should have been given to residents or their representatives did not include mandated details about appeal rights, how to request an appeal, or how to contact the State LTC Ombudsman. The Social Services Director reported that she does not notify the Ombudsman of hospital transfers and only sends a monthly email list of discharged residents, without written copies of transfer or discharge notices.
A resident was transferred to the hospital for shortness of breath, and the facility failed to document the specific number of bed-hold days on the Bed Hold Notice Agreement at the time of transfer. Nursing staff reported they routinely entered a default number of days because they did not know the actual bed-hold entitlement, while the Business Office determined the true number of days later by contacting the family. In addition, Social Services did not send transfer/discharge notifications to the Ombudsman, and the Administrator had been emailing notifications to an incorrect Ombudsman address, contrary to the facility’s own transfer and discharge policy requiring written notice, appeal-rights information, and Ombudsman notification.
A resident was transferred to the hospital due to blood in her vomit, but staff did not complete the required written Transfer Notice or Bed Hold Notification, nor did they send a copy of the Transfer Notice to the Ombudsman. Record review confirmed the absence of these documents in the resident’s medical record, and the Social Services Director acknowledged that staff were expected to complete these notices and notify the Ombudsman whenever a resident was transferred to the hospital.
Surveyors found that two residents were transferred to the hospital—one for abnormal labs, cancer treatment, PEG tube feeding needs, bedbound status, and COVID positivity, and another for behavioral symptoms including agitation and psychosis—without required written transfer notices, appeal rights information, or bed-hold notifications being provided to them or their representatives, and without written notice being sent to the Ombudsman. Record reviews showed no transfer or bed-hold documentation in either medical record, and the SSD acknowledged she had not been notifying the Ombudsman of discharges and saw no nursing notes regarding transfers, discharges, or bed-hold notices. The DON stated she was unaware that nursing was responsible for the transfer and bed-hold notice process, despite expecting that nursing and the business office would send these notices within 24 hours.
Surveyors found that two discharged residents did not have discharge summaries in their medical records. Review of facility documentation confirmed that both residents had been discharged, but no discharge summaries were completed or filed. In an interview, the ADON acknowledged that staff should have completed these discharge summaries and that they were expected to be present in the medical record.
A resident with dementia, behavioral disturbance, CKD, and other comorbidities was involved in two separate sexually inappropriate incidents with another resident. After the first incident, the facility generated a written discharge notice citing safety concerns and including appeal information, but key fields such as the discharge planning conference date were left blank and there is no clear evidence the representative actually received it. Following a second similar incident, a second discharge notice was created with an undated 30‑day notice period and no conference date, and the Social Services Director reported sending both notices with the transport driver at the time of discharge. The resident’s spouse stated she was only called and told he had to leave immediately, did not receive any written discharge notice, and was unaware of her appeal rights, demonstrating a failure to provide required written discharge notification to the resident’s representative.
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