Surveyors determined that the facility did not send the required transfer notice to the State LTC Ombudsman when a resident with vascular dementia, post-stroke sequelae, constipation, and atrial fibrillation—who had documented memory impairment, behavioral symptoms, and dependence for toileting and transfers—was sent to the hospital via ambulance. A nursing note recorded the transfer, but there was no documentation that the Ombudsman was notified. During interviews, the Director of Social Services and the Assistant Administrator stated that Ombudsman notifications for hospitalizations and discharges were usually emailed in batches and acknowledged that no email notification for this transfer could be located, characterizing the omission as an oversight.
Missing Ombudsman Notifications and Bed Hold Policy Notices: The facility did not document sending transfer/discharge notices to the State LTC Ombudsman for several residents who were sent to the hospital, and it did not provide bed hold policy notices to resident representatives when residents were transferred or hospitalized. A resident with dementia and psychotic disturbance, a resident with dementia, HTN, and DM, and another resident with dementia, BPH, and HTN were all transferred without documented Ombudsman notification or bed hold policy notice; another hospitalized resident also did not receive a bed hold policy notice.
The facility did not complete or send required transfer/discharge notices to residents, their representatives, or the Ombudsman for three residents who left the facility. One resident was sent to the hospital by EMS for abdominal pain and distention, another discharged AMA after a family discussion, and a third was taken to the hospital after a reported fall and hip refracture. An Ombudsman email confirmed missing discharge notifications, and an AA stated the notices had not been sent because there was no Social Worker.
Surveyors found that the facility did not send required copies of transfer/discharge notices to the State LTC Ombudsman for two residents who were transferred to the hospital, one with a hip fracture and dementia and another with dementia and breast cancer experiencing uncontrolled pain and later hospice planning. Although transfer/discharge forms and bed-hold documents were completed and kept in a binder, the Director of Social Work acknowledged that no copies or monthly transfer/discharge lists had been sent to the Ombudsman for several months, and the Ombudsman confirmed not receiving notices or monthly lists during that period.
The facility failed to follow required transfer/discharge procedures for three residents with dementia, bipolar disorder, depression, anxiety, and polyneuropathy by not providing timely, complete written notices to them, their representatives, and the State LTC Ombudsman. One cognitively intact resident with dementia and diabetes was moved to a locked unit without documented wandering assessments, without a completed discharge plan, and without a signed notice or timely notification to the representative. Another cognitively intact resident with dementia and bipolar disorder was discharged with a notice dated one day before discharge and no resident signature. A third resident with moderate cognitive impairment reported staff packed and moved them without prior notice; documentation showed a late-entry note stating the resident was notified and given discharge paperwork upon discharge, and the discharge notice used "verbal consent" instead of the resident’s signature. The Ombudsman reported not receiving discharge notices for these moves and stated the facility had been using outdated forms that did not meet current regulatory requirements, while the Administrator acknowledged only issuing 30-day notices when residents were discontent with leaving.
Failure to Notify Ombudsman of Resident Transfer: A resident with severe cognitive impairment, dementia, and dependence for mobility and transfers sustained a fall, was found in pain, and was transferred to the hospital after x-rays showed a left hip fracture. The facility did not send the required transfer/discharge notice to the Office of the State LTC Ombudsman, and the DOSS and Administrator confirmed the notice was not sent.
A resident with significant care needs was discharged without all necessary information being sent to the home care agency, resulting in a delay in the initiation of home care services. The facility did not provide required documentation such as demographics and orders, causing the agency to be unable to process and start services as expected.
Failure to Provide Written Transfer/Discharge Notice: A resident with intact cognition, anxiety disorder, bipolar disorder, and COPD was transferred to the hospital, but the facility did not complete or provide a written transfer/discharge notice in a language and manner the resident could understand. Record review found no notice in the chart, and interviews showed the SWD, DON, and Administrator were aware of the notification process but could not confirm the resident received it.
Failure to Provide Required Transfer and Ombudsman Notices: The facility did not complete written transfer/discharge or bed-hold notices, and did not notify the ombudsman, for three residents reviewed after hospital transfers or discharge home. The affected residents had significant medical and cognitive impairments, including COPD, adult failure to thrive, pneumonia, diabetes, intellectual disability, sepsis, and cerebral palsy, and staff could not locate proof that the required notices were sent.
Missing Transfer, Discharge, and Bed Hold Notifications: The facility did not complete required transfer/discharge notices or bed hold notification for one resident who was hospitalized, and the Ombudsman was not notified of that resident's transfer/discharge or of another resident's discharge to the community. The DON said nursing was responsible for informing the family about bed hold policy, and the DOSS said she was responsible for sending Ombudsman notices, but neither could provide documentation that the required notifications were made.
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