A resident with diabetes, HTN, bipolar disorder, anxiety, and a right AKA was discharged with only part of her belongings. The rest of her property, including a broken-down mini-van, remained at the facility while staff gave conflicting accounts about transport and follow-up. The resident later reported she could not reach anyone about retrieving her items, and the DON and Administrator confirmed the belongings were still there.
A resident with cancer, depression, and chronic pain left after discharge planning was completed, but the resident did not receive the discharge summary, paperwork, or needed medications. The RN left to retrieve the items, and the resident departed before they were handed over. Records showed the meds were not sent with the resident, mailed, or delivered to a pharmacy, and there was no documented notification to the PCP or home health agency.
Failure to Notify Ombudsman and Assist with Discharge Planning: The facility failed to notify the Ombudsman after one resident was hospitalized and transferred for a hip fracture repair, with post-op needs including pain mgmt, wound care, PT/OT, and extensive ADL assistance. The facility also failed to assist another resident with discharge planning when the resident's POA requested a transfer to another facility, and staff had no documentation showing the transfer was completed or followed up.
A resident with COPD, chronic respiratory failure, diabetes, CKD, dementia, a G-tube, and multiple wounds developed a change in condition with congestion, decreased lung sounds, fever, low BP, and abnormal labs. When the resident was transferred to the ER for septic arthritis, osteomyelitis, aspiration pneumonia, and a UTI, there was no documentation that the nurse called report or sent the associated lab results, and the ER MD documented that no report was received.
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.
Failure to Notify Ombudsman of Resident Transfers and Discharges: The facility did not notify the State Ombudsman of several resident discharges and a hospital transfer. A resident with intact cognition and multiple chronic conditions was discharged home after NP orders, two other residents with significant care needs were also discharged, and another resident with impaired cognition and total dependence was discharged home; a fourth resident with stroke-related deficits and CKD was transferred to the hospital for chest pain. Interviews confirmed no Ombudsman notices were sent.
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.
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