Failure to Send Transfer Information and Provide Bed-Hold Notice: The facility did not document that necessary clinical information was sent to the receiving provider when several residents were transferred to the hospital, including residents with CHF, AFib, dementia, CVA history, respiratory failure, sepsis, pneumonitis, depression, HTN, and weakness. The facility also lacked evidence that written bed-hold policy information was given to residents and/or their representatives at transfer, despite policy requiring notice of bed-hold rights, reserve bed payment details, and the per diem rate to hold the bed.
Failure to Provide Bed-Hold Notice and Transfer Information: The facility did not provide written bed-hold policy notice to two residents or their representatives when they were transferred to the hospital, and their records lacked evidence that necessary clinical information was communicated to the receiving provider. One resident had breast cancer, dementia, and A-fib; the other had COPD, respiratory failure, and diabetes. The DON confirmed the missing documentation.
The facility failed to send written discharge notices to the Office of the State LTC Ombudsman for two residents who were discharged. Clinical record review showed no documentation that the notices were provided, and the Social Services Director confirmed the notices were not sent.
The facility failed to communicate necessary resident information, including care plan goals, to receiving providers for four residents who were transferred to the hospital and expected to return. The residents had diagnoses including HTN, HF, depression, dysphagia, pain, weakness, and muscle wasting. The facility also did not notify the State LTC Ombudsman of two resident discharges, and the SW stated that the facility does not send these discharge notifications.
Failure to Notify Ombudsman of Hospital Transfers: The facility did not notify the LTC ombudsman of hospital transfers for five residents. The residents had varied conditions including HF, pneumonia, respiratory failure, a feeding tube, cerebrovascular disease, diabetes, dementia, falls, and difficulty breathing. Events included low O2 sats, a feeding tube dislodgement, numbness spreading to the shoulder, hypoglycemia with unresponsiveness, a fall with bleeding, and respiratory distress. The DON confirmed there was no documented evidence of ombudsman notification for these transfers.
Failure to Provide Written Transfer and Bed-Hold Notices: The facility did not provide written transfer notices or bed-hold policy notices to responsible parties for multiple residents sent to the hospital. Records showed several hospital transfers, including a resident who was found on the floor and later sent out again for chest pain, but only verbal communication was documented for the resident’s wife. The DON and NHA confirmed there was no evidence that the required written notices were provided, and one transfer form listed the LTC Ombudsman email address incorrectly.
The facility failed to notify the State Ombudsman’s office of hospital transfers for two residents. One resident had two acute care transfers and returns, and another resident was transferred with pneumonia and returned shortly after, but the records showed no evidence that either resident’s transfer was reported. The NHA confirmed the notifications were not properly made.
Failure to Communicate Required Transfer Information: The facility failed to send required transfer information to the receiving provider for two residents. One resident was transferred to the ED twice for evaluation of a wound, but the record did not show that the physician’s contact information, resident representative information, advance directives, care plan goals, special instructions, or wound treatment details were communicated. A second resident’s transfer record also lacked evidence of the required clinical and contact information, and the DON could not produce documentation showing the information had been sent.
The facility failed to ensure that resident representatives received written transfer notices and bed-hold policy notices as soon as practicable for two residents sent to the hospital. One resident had two ER transfers, including one at the resident's request and another for pain evaluation, with no evidence of written notice to the RP. For another resident, the chart showed only a phone notification, and the NHA and DON could not provide documentation that the RP received the notice in writing.
Failure to Communicate Required Transfer Information: The facility failed to ensure that necessary resident information was sent to the receiving provider for a resident transferred to the hospital and later returned. The record lacked documentation of care plan goals, advance directive info, ongoing care instructions, resident representative info, and other details needed to meet the resident's specific needs; an RN confirmed the missing communication.
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