A resident with severe cognitive impairment and multiple diagnoses, including pneumonitis, AFib, AKI, diabetes, and malnutrition, was transferred to a hospital-level of care. The record did not show written notice of the reason for transfer/discharge was provided to the resident or representative, and there was no evidence that a bed-hold offer was made; the Regional Nurse stated there was no discharge paperwork available.
Facility staff failed to provide required discharge instructions and documentation to two residents who left AMA. One resident with multiple acute and chronic conditions and moderate cognitive impairment left shortly after admission, and nursing notes only recorded that the resident left with family and signed AMA paperwork, with no evidence of discharge instructions or a recapitulation of the stay being provided, consistent with the DON’s statement that discharge summaries are not given for AMA discharges. Another resident with a hip fracture and intact to moderately impaired cognition was discharged by staff after the son arrived unexpectedly, with non‑narcotic medications provided but no documented discharge orders, and the receiving facility reported that it received only a face sheet and PASRR because the discharging facility stated it would not send additional records due to the AMA status, leaving the admitting facility without an H&P, clinical notes, or a medication list.
A resident with severe cognitive impairment was sent to the ER after copious pus was found at the G-tube site, and the RR was notified. However, the facility had no evidence that a written transfer/discharge notice with appeal rights was provided to the resident or RR, and the Administrator stated he was unaware of the requirement for the notice and appeal process.
A resident with severe dementia and other significant diagnoses was transferred to a higher level of care, but the facility did not have evidence that the resident's representative received written notice of the reason for the transfer/discharge. The CD stated a transfer form was given to the resident at the time of hospital transfer, but could not confirm that the legal representative was informed in writing as required by facility policy.
Facility staff failed to provide a resident and their representative with required written notice of discharge reasons and bed-hold options when the resident was sent to the hospital, and also did not document that clinical transfer information, including care plan goals and other key data, was sent to the receiving hospital. Although an LPN reported that her usual practice is to communicate critical information by phone and send printed clinical summaries with EMS, the resident’s record contained no evidence that the required bed-hold notice or continuity of care documents were provided for this transfer, contrary to facility policies on patient transfer and bed reserve.
Failure to Provide Written Transfer Notice: A resident was transferred to the hospital for fever, low O2, and a slow response, but the facility did not provide a written transfer notice to the resident, the resident representative, or the ombudsman. The DON/Social Services process described mailing notice to family, documenting it on a form, and sending weekly encrypted emails to the ombudsman, but no notice was found in the record or ombudsman binder.
Missing transfer and bed hold notice: A resident with TIA and moderately impaired cognition was sent to the hospital after becoming unable to speak and having weak bilateral hand grips. The EMR did not show documentation that the written transfer notice and bed hold policy were provided to the resident and/or RP, and staff gave inconsistent descriptions of how the forms were handled and whether the RP received the information.
Facility staff failed to notify the state LTC ombudsman of a resident transfer/discharge to a higher level of care. The resident had multiple serious diagnoses, including sepsis, CKD stage 3, AFib, malnutrition, and moderate cognitive impairment (BIMS 8/15), and was sent to the ER for Hgb 7 and severe abdominal pain. SW stated the transfer/discharge list was printed, but there was no evidence it was sent to the ombudsman.
Failure to Provide Written Transfer and Bed Hold Notices The facility did not provide written transfer notices and bed hold notices for several residents who were sent to the hospital. One resident was transferred after becoming extremely drowsy and altered from baseline, another called 911 for an ER transfer, a third was sent out after hypotension during dialysis, and a fourth was transported after staff found him slumped over and hard to arouse. Staff and leadership could not find documentation showing the required notices were given, and one resident stated she never received any paperwork related to the transfer or bed hold.
Facility staff discharged a resident with multiple chronic conditions and moderately impaired cognition to a group home without providing written notice to the court-appointed legal guardian, despite a court order granting the guardian authority over all placement decisions. The clinical record lacked a physician-documented rationale for discharge, a documented discharge plan, or evidence of guardian involvement or consent, and only contained social services notes referencing discussions with the resident and the group home. The discharge summary listed the group home address and claimed medication reconciliation was completed, but omitted several medications that a NP had documented should be continued for conditions such as CHF, diabetes, hyperlipidemia, vitamin deficiency, and prior cerebral infarction, and there was no clear evidence that discharge instructions were provided to the resident, representative, or receiving provider.
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