A resident with vascular dementia was discharged home with discharge orders and a medication release form, but the clinical record contained no documented discharge summary for the discharge. The Administrator stated that no discharge summary was completed.
A facility failed to develop a system to notify the State LTC Ombudsman's office of resident transfers. A resident with thoracic spine fusion was transferred to the hospital for emergency spinal surgery, and staff interviews confirmed there was no established process for notifying the Ombudsman's office of transfers or discharges, despite the facility policy requiring notice when practicable.
Failure to Provide Bed-Hold Notice and Ombudsman Notification: The facility failed to give a written bed-hold notice when one resident was transferred to the hospital and failed to notify the State LTC Ombudsman of the discharge for two residents. One resident had streptococcal infection and respiratory failure and was transferred to the hospital, while another resident with surgical aftercare and morbid obesity was discharged after leaving AMA. The Administrator confirmed the Ombudsman had not been notified.
Incomplete Discharge Summaries: The facility failed to complete discharge summaries for multiple residents, including a recapitulation of the resident's stay and functional status upon discharge. A resident with pneumonia, a resident with kidney cancer, and a resident with dementia all had discharge paperwork that omitted this required information, and the Social Services staff member acknowledged the omissions.
Failure to Provide Bed Hold Notices and Discharge Referral Information: The facility did not provide written bed hold notifications, including reserved bed hold payment details, when a resident with HF and DM was transferred to the hospital multiple times. The facility also did not ensure a cognitively intact resident with fractures and respiratory failure received a timely home health referral after discharge; records and staff statements showed the agency did not receive the referral from the facility until it was later completed by an NP.
A resident was transferred to the hospital after a change in condition, but the facility did not provide the required bed hold policy at the time of transfer. The policy required written notice upon admission and again at transfer or within 24 hours for an emergency transfer. Staff interviews confirmed the resident was not given the policy, and the LPN, RCM, and DNS acknowledged the omission.
Failure to notify the State LTC Ombudsman office of a resident’s discharge. A resident admitted with respiratory failure was discharged, but the clinical record did not show Ombudsman notification, and the discharge list sent to the Ombudsman did not include the resident. The BOM verified the resident was omitted from the list, and the Administrator stated that a complete list of discharged residents was to be sent.
A resident with a stroke history and moderate cognitive impairment was hospitalized, but the record did not show that the resident or family received bed hold information. The family said no bed hold notice was provided, while staff reported that the policy was sent in a transfer packet and that follow-up to confirm receipt was not consistently done; the DON and admissions director gave differing accounts, and the administrator said bed hold information was mainly directed toward skilled residents.
A resident with CHF and epididymitis was transferred to the hospital for scrotal swelling, but the clinical record did not show that a written bed hold notice was given to the resident or representative. The DNS stated the charge nurse was responsible for providing the bed hold policy at transfer, and the Administrator confirmed the form was not completed.
A facility failed to notify the State LTC Ombudsman Office of resident discharges as required by policy. The Business Office Manager stated the discharge list had not been sent for several months, and the Administrator acknowledged the monthly update was missed due to business office staffing changes.
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