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.
Failure to Provide Required Discharge Notice and Appeal Rights: A resident with Alzheimer’s disease, bipolar disorder, severe cognitive impairment, and significant behavioral issues was transferred to another SNF without the required written 30-day notice to the RP or Ombudsman. The SW did not provide the reason for the discharge, the destination, the effective date, or appeal rights in writing, and the RP reported learning of the move only after the receiving facility contacted him.
Failure to Send Discharge Notices to Ombudsman: The facility issued 30-day discharge notices for two residents with dementia and moderately impaired cognition, but did not mail copies to the State LTC Ombudsman as required. The BOM confirmed the notices were prepared and sent to family members, and the Administrator confirmed the Ombudsman was not provided a copy until after surveyor intervention.
Failure to Provide Required Discharge Notice and Notifications: A resident with dementia, schizophrenia, intellectual disabilities, and severe cognitive impairment was facility-initiated discharged after an inappropriate touching incident, but the facility did not provide a written discharge notice in a language and manner the resident and RP could understand, did not include appeal rights or Ombudsman information, and did not notify the LIDDA despite PASRR-positive status. Staff also could not find physician documentation supporting the basis for the discharge or emergency transfer.
Failure to Notify Legal Guardian Before Resident Discharge: A resident with epilepsy, cerebral palsy, and severe cognitive impairment was discharged to a group home without the legal guardian being notified beforehand. The SW spoke with the guardian about placement but did not provide a discharge date or obtain permission for the transfer, and the LVN only left messages requesting a return call. The guardian learned of the discharge the next day, filed a grievance, and the receiving facility stated it had not accepted the resident or agreed to the discharge date.
Failure to Notify Ombudsman of Resident Transfer: A resident with COPD, CHF, CKD, and moderate cognitive impairment was transferred after stating she wanted a fresh start at another facility. The DON and Administrator believed a 30-day notice was not required because the move was resident-initiated, but the Ombudsman reported no written or verbal notice and learned of the transfer only after seeing the resident elsewhere. The Social Worker could not provide proof of Ombudsman notification and said she did not know the correct procedure when a 30-day notice was not required.
Failure to Provide Written Transfer/Discharge Notices: The facility failed to give written transfer or discharge notices to three residents or their RPs and instead relied on phone calls. One resident had CHF, AFib, and DM, and two residents had DM with severely impaired cognition on MDS. Family members stated they never received written notice, and the facility’s policy required written notice with the reason for transfer/discharge, appeal rights, and LTC Ombudsman information.
Failure to Provide Written Transfer or Discharge Notices: The facility did not give written transfer or discharge notices, with reasons for the move, to three residents or their representatives, and did not send copies to the State LTC Ombudsman. One resident had severe cognitive impairment and was transferred to the hospital twice, another had moderate cognitive impairment and was sent out after a fall and leg pain, and a third had a planned discharge home. The Social Worker and DON stated that only transfer forms or 30-day notices were handled, and the discharge policy did not require written resident notification.
Failure to Notify Ombudsman of Discharge Notices: The facility did not send discharge notices to the Ombudsman for two residents before discharge. One resident had dysphagia, HTN, and osteoporosis, and the other had COPD, acute respiratory failure, and syncope. Staff stated they only notified the Ombudsman for unplanned discharges, while facility policy required notice when the discharge notice was given to the resident or representative.
Failure to Notify Ombudsman of Resident Discharge: A resident with dementia, severe cognitive impairment, wandering, and escalating aggression was sent to the hospital after an altercation with staff and was not allowed to return. The Ombudsman stated she did not receive discharge notice, and the RP stated he did not receive a 30-day notice or email about the discharge. The DON and Administrator acknowledged the RP and Ombudsman should have been notified.
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