A resident with multiple serious diagnoses and moderate cognitive impairment was moved to another facility after a confused transfer process involving the SW, family, dialysis staff, and transport company. The resident’s representative was not properly notified in writing of the discharge, the reason for the move, or appeal rights, and the Ombudsman was not informed. Text messages and staff interviews showed conflicting information about whether the transfer was canceled or still planned, and the family reported not being told the resident had been moved or receiving discharge paperwork or meds.
Failure to Notify Ombudsman of Discharge Notice: A resident with significant ADL dependence, bowel and bladder incontinence, and multiple serious diagnoses was given a 30-day discharge notice for non-payment, but the facility did not send the notice to the Ombudsman at the same time the resident was notified. The Ombudsman first received the notice later by e-mail, and the record lacked documentation of timely Ombudsman notification.
A resident with multiple chronic conditions, including AFib, chronic respiratory failure, DM, dementia, schizophrenia, and bipolar disorder, left the facility with family without signing out and without her meds or belongings. Staff documented repeated attempts to locate her while she remained out of the facility beyond the bed-hold limit, and she later returned from the hospital with CHF exacerbation. The EHR had no AMA form or discharge summary with a recapitulation of stay, current health status, or post-discharge plan.
Failure to Provide Written Transfer Notice and Ombudsman Notification: A resident with diabetes, a femur fracture, chronic pain syndrome, and heart disease was transferred to the ER after insisting on hospital transfer. The facility notified the resident's family and the ER physician verbally, but did not provide written transfer/discharge notice to the resident or representative and did not send a copy to the State LTC Ombudsman, according to the DON and family interview.
A resident with spinal stenosis, DM2, and moderate cognitive impairment was discharged after discharge planning discussions about a hotel stay, home health, and community transition, but he and his representative were not given written notice of discharge, the reason for the move, or appeal rights in a language and manner they understood. Staff also did not send the required notice to the Ombudsman, and the discharge paperwork left the destination blank.
A resident with severe cognitive impairment, psychotic disorders, and repeated exit-seeking was transferred to another SNF with a secure unit, but the facility did not give the RP written discharge notice, did not include the reason for the move or appeal rights in writing, and did not send the required notice to the Ombudsman. Staff documented phone discussions and progress notes, but the RP said she never received written information or appeal instructions.
Failure to Provide Required Transfer/Discharge Notice and Ombudsman Copy: A resident with Parkinson’s disease, dementia, and moderate cognitive impairment was transferred to another sister facility, but the ADM stated that no 30-day written discharge notice was provided to the resident or party responsible and no copy was sent to the Ombudsman. The resident’s care plan documented aggression, resistance to care, and barricading in the room, and the Ombudsman confirmed the notice was not provided.
Missing Discharge Summary and Medication Reconciliation: A resident with spondylosis, Alpers Disease, protein calorie malnutrition, myopathy, and hyperlipidemia discharged home with family, but the chart contained only a discharge progress note summary and no Discharge Summary. The record lacked the required recapitulation of the stay, final status, and reconciliation of pre-discharge and post-discharge meds, and both the DON and SW acknowledged the missing documentation.
Failure to Provide Written Discharge Notice and Appeal Rights: A resident with multiple vascular and wound-related diagnoses and moderate cognitive impairment was discharged after staff determined she no longer had a skilled need and her insurance would not continue coverage. Staff discussed discharge plans and a 48-hour notice, but the BOM said no written discharge letter was needed and there was no appeal opportunity because no written notice was given. The resident stated she was not given a written discharge letter, was told her time was up, and tried to make a verbal appeal.
Missing Discharge Summaries for Four Residents: The facility failed to complete discharge summaries for four residents who were discharged to an acute care hospital or home. The residents had significant diagnoses including CKD, HF, sepsis, metabolic encephalopathy, rhabdomyolysis, cerebral atherosclerosis, and DM2. Record review showed no completed discharge summary in the EHR for any of the four residents, and interviews confirmed nursing staff and the SW were responsible for the discharge summary process, with the nurse on duty expected to complete it at discharge.
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