Missing Ombudsman Notifications for Hospital Transfers: The facility failed to document that written transfer notices were sent to the Ombudsman for 3 residents who had multiple hospital transfers. One resident had repeated EMS transfers for severe pain, nausea/vomiting, and hyperglycemia; another had transfers for yelling, respiratory distress, and a fall with laceration; and a third had transfers for abdominal pain, vomiting, and dark red stool. The ADM stated discharge summaries were completed before hospital transfers, but he could not locate Ombudsman notifications, though he said it was part of the process.
Missing transfer documentation for ER transport: A resident with multiple diagnoses, including metabolic encephalopathy, sepsis, and HTN, was found on the floor after a fall and was sent by EMS to the ER for right hip evaluation. The nursing note documented the fall and transfer, but the chart did not document the information sent to the receiving provider; the later discharge/transfer summary was completed hours after the transfer and did not show what was conveyed with EMS.
A resident with Parkinson's disease and a history of TIA/CVA had coffee-ground emesis and severe hypoxia, was sent to the hospital by ambulance after the on-call provider ordered transfer, and family and nurse management were notified. The chart included a note about the change in condition and a later note confirming hospital admission, but it did not document what records were sent with the resident; staff said they normally send the face sheet, med list, treatments, POLST, and related paperwork and document the transfer in a progress note.
A deficiency was identified when a resident who was sent to the ER and then discharged from the facility did not receive the required written discharge notice. Review of the medical record showed no written notice, even though hospital documentation stated the resident could not return because the facility could not ensure her safety. The facility’s policy required written notification to the resident and representative, including the discharge reason, effective date, destination, appeal rights, and Ombudsman/advocacy contact information. The Administrator confirmed that only verbal notification was given and that no written discharge notice was provided.
Missing transfer documentation, Ombudsman notification, and bed-hold information. A resident with fluid overload and two other residents with significant medical issues were transferred to the hospital or ER, but the chart did not document what information was sent to the receiving provider. Staff also reported that transfer summaries were not completed, and the Ombudsman notification and bed-hold policy were not consistently included with resident transfers.
A resident was transferred to the hospital after becoming unarousable, but the medical record did not document what information was sent to the receiving provider. RN staff stated that transfer packets typically include a face sheet, bed hold copy, and med list, and the DON said transfer documentation should also include the provider order, hospital transfer agreement, POLST, and transfer sheet; however, none of that transfer documentation was found in the resident’s record.
Incomplete discharge and transfer documentation: The facility failed to keep complete discharge/transfer records for several residents. For one resident discharged after aspiration-related illness, the chart lacked the discharge location; for another resident transferred to the ED, the chart did not show what paperwork accompanied the transfer; for a third resident discharged with HH, the chart did not document what documents or meds were sent; and for a fourth resident discharged after a femur fracture, the chart lacked a discharge summary. The DON stated the discharge progress notes were believed to cover the required information, but the paperwork could not be located in the medical record.
A resident with multiple diagnoses was transferred to the ER after a fall, elevated BP, and chest pain, but the chart lacked a completed transfer/discharge assessment and did not show what information was sent to the receiving provider. The record also had no documentation that the Ombudsman was notified of the transfer, and interviews with the RA, RN, and DON confirmed the missing documentation.
A resident with poly neuropathy, systolic HF, atrial fibrillation, and CKD left the facility AMA to stay at a women's homeless shelter for help with low-income housing. The MD was notified, the resident signed an AMA form, and family picked up belongings, but the State Long-Term-Care Ombudsman notification was not documented. The Resident Advocate stated she emails the ombudsman for resident discharges but could not find proof that the ombudsman was notified for this discharge.
Missing transfer/discharge documentation and bed hold notice: The facility did not document the transfer or discharge of 3 residents in the medical record or show what information was sent to the receiving provider. One resident discharged to the hospital was not given a bed hold notice, and records for the residents did not identify where they were transferred or discharged to.
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