The facility failed to document that necessary resident information was sent with three hospital transfers, including care plan goals, advance directive information, ongoing care instructions, and resident representative information. It also failed to notify two residents or their representatives of the bed-hold policy and failed to notify the State LTC Ombudsman for three hospital transfers. The DON and Regional Director of Clinical Services confirmed the missing documentation and notifications.
Failure to Provide Bed-Hold Notice at Transfer: The facility failed to ensure that written bed-hold policy notice was given to the resident and/or representative at the time of hospital transfer for four residents. The affected residents had diagnoses including dementia, CKD, diabetes, HTN, AFib, anxiety, and depression, and were transferred for issues such as abdominal pain, coughing up blood, altered mental status, elevated BP, UTI, and pneumonia. The NHA confirmed Medicaid residents were not provided bed-hold information upon transfer, and the DON and NHA confirmed the lapse.
Failure to Notify Residents, Representatives, and Ombudsman of Hospital Transfers: The facility did not provide written notice to residents or their representatives explaining the reason for hospital transfer, and it did not notify the ombudsman of the transfers. Affected residents included cognitively intact and cognitively impaired residents transferred for altered mental status, hematuria, lethargy, falls, change in condition, dysphagia, dyspnea, choking, and bleeding, and the DON confirmed the missing notifications.
Failure to notify the State Ombudsman of emergency hospital transfers was identified for four residents. Records showed transfers for residents with conditions including ileus, sepsis, and pneumonia, but documentation did not show that the Ombudsman was notified of the hospital transfers and admissions.
A facility failed to provide written notice to the resident and the resident's representative or legal representative explaining the reason for discharge for three residents who were transferred to the hospital after a change in condition. Clinical records contained no evidence that written notification was given, and the NHA and an RN confirmed the lack of documentation.
The facility failed to provide written transfer notices to the Office of the LTC Ombudsman for two residents who were sent to the hospital. One resident had anemia, hemiplegia/hemiparesis after a CVA, and muscle weakness, while the other had dementia, DM, and major depressive disorder. The NHA confirmed the missing notices during interview.
A resident with a left femur fracture, muscle weakness, difficulty walking, and orthopedic aftercare was transferred to the hospital, but the clinical record lacked documentation that the resident and/or representative received the required bed-hold policy notice explaining bed-hold duration and daily cost. The record also lacked evidence that necessary resident information was communicated to the receiving hospital, and the DON confirmed both omissions.
Missing Transfer Notice and Bed-Hold Policy Documentation: The DON confirmed that the facility failed to document a written transfer notice for one resident who was not responsible for self and failed to document that another resident or the resident's representative received written bed-hold policy information during hospital transfers. The residents had diagnoses including HTN, anemia, adult failure to thrive, anxiety, depression, and ALS.
Failure to provide required transfer notifications: A resident was transferred to the hospital after a change in condition, but there was no documented evidence that the resident’s RP or legal representative received written notice of the transfer and reason for the move. In addition, written discharge or transfer notices were not sent to the Office of the State LTC Ombudsman for four other residents who were transferred to the hospital after changes in condition.
Failure to Send Discharge Notices to the Ombudsman: The facility did not provide copies of written discharge notices to the Office of the State LTC Ombudsman for three residents who were discharged. Clinical record review found no documented evidence that the required notices were sent, and the Administrator confirmed the omission in interview.
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