Failure to provide required transfer and closure notifications: The facility transferred all residents due to a temporary closure for renovations but did not give 30-day written notice to residents or their reps. The DON, Administrator, and other staff confirmed families were told by phone or email, but there was no documentation of the calls, and one POA said notice was given only when the resident moved out. The facility also delayed notifying the State LTC Ombudsman and did not show receipt of the closure plan by the State Agency.
Missing Transfer and Bed Hold Notices: A resident with sepsis, cystitis, DM2 with ketoacidosis, malnutrition, and generalized weakness had a significant change in condition, became unresponsive, and was transferred to the hospital after EMS was called and O2 was started. The record had no documentation that a bed hold notice or transfer notice was given to the resident or resident representative, although the facility did document Ombudsman notification.
Failure to Notify Ombudsman of Resident Discharge: The facility did not notify the State LTC Ombudsman Office of a resident’s discharge. The resident had diagnoses including alcohol abuse, muscle weakness, and difficulty walking, and was discharged to personal residence. Review of the Ombudsman Transfer/Discharge Log showed the discharge was omitted, and the Administrator verified the information was not sent as required.
The facility failed to include bed hold pricing information on bed hold notices and failed to document the reason for transfer/discharge notices to the resident/representative and the Ombudsman for three residents. Records showed hospital transfers or discharge related to emergent health changes, but the bed hold forms left the room and board rate blank, and staff confirmed they had been instructed not to complete the pricing section. There was also no documented evidence that the required discharge notice content was provided.
Failure to Provide Written Discharge Notice: A resident with Alzheimer’s disease and severe cognitive impairment was discharged after staff verbally told the wife the resident needed to go to a psych facility because of behaviors, but no written 30-day discharge notice was issued. Hospice documentation and staff interviews confirmed the lack of written notice, despite facility policy requiring advance written notice to the resident and representative.
The facility failed to provide required transfer/discharge notices and failed to notify the Ombudsman of all transfers and discharges. One resident had multiple hospital transfers for trach issues, altered mental status, hyperglycemia, sepsis, UTI, and lethargy, but there was no evidence that the resident or representative received transfer notices and one transfer was omitted from the Ombudsman list. Another resident was transferred to the ER for vomiting and abdominal pain without evidence of a transfer or bed hold notice, and a third resident was discharged home without evidence that the Ombudsman was notified.
A resident with CHF, bipolar disorder, and knee pain was discharged with new orders for doxycycline and prednisone, and the nurse reviewed the discharge instructions and meds with the resident and spouse. However, the RN confirmed she did not call the prescriptions to the pharmacy to ensure the resident could obtain the ordered discharge meds, and the NP stated nursing staff normally handled pharmacy calls for home meds.
Failure to Provide Transfer Notice and Ombudsman Notification: The facility failed to provide a written transfer notice for a resident discharged to the hospital and failed to notify the LTC Ombudsman of discharges for two residents. One resident was severely cognitively impaired and dependent for most ADLs, while the other had HIV, depression, homelessness, and limited support, with discharge planning noting no housing or finances. Staff confirmed the transfer notice was not given and ombudsman notifications were not made.
Missing Bed Hold and Transfer Notices: A resident with schizophrenia, depression, anxiety, HTN, and cognitive communication deficit had multiple hospitalizations, but the facility could not locate transfer notices for any of them. Bed hold forms were only signed for two hospital stays, while later forms were unsigned and had blank certified mail labels attached, and staff confirmed there was no way to verify when or where the notices were sent.
Bed-Hold Notices Lacked Required Duration Information: The facility failed to provide written bed-hold notices that specified the duration of the bed-hold policy and the number of bed-hold days used or remaining for two residents transferred to the hospital. One resident had SOB, diminished lung sounds, and low O2 sat before EMS transfer, and another had sharp chest pain radiating to the jaw and clavicle before ER transfer. The SSD confirmed the notices did not include the required bed-hold details.
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