The facility failed to ensure signed bed hold documentation was included with hospital transfer paperwork for three residents. One resident had DM and moderate cognitive impairment, while two others had severe cognitive impairment and complex medical conditions; the record also lacked a written transfer notice for one resident and did not show bed hold or transfer notice documentation for the others. The Administrator and Admissions Director stated the bed hold forms were sent in the packet but were not signed.
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.
Failure to send required transfer paperwork and bed hold notices: The facility did not document that required clinical information was sent with residents transferred to the hospital, and it also failed to provide bed hold notices and care plan goal summaries for other residents. One resident had CHF, GERD, spinal stenosis, and HTN; another had ESRD, hemodialysis, and DM and was sent out after becoming lethargic and hard to arouse. Staff gave conflicting accounts about whether nursing or admissions was responsible for the transfer paperwork and bed hold notifications.
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 PNA, sepsis, acute respiratory failure, and CHF was transferred to the hospital for SOB and functional decline, but the facility had no evidence of a progress note or eINTERACT form documenting the transfer. The DON confirmed there was no clinical documentation sent with the resident, despite the facility policy requiring transfer information such as practitioner contact details, representative information, advance directives, care plan goals, and other necessary records.
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.
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