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.
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.
Failure to Provide Transfer/Discharge Notice and Bed-Hold Policy: Two residents did not receive required written transfer/discharge information. One resident with severe cognitive impairment had no documented written notice to the representative for the hospital transfer and no evidence the bed-hold policy was provided. Another cognitively intact resident transferred for acute heart failure also had no documented bed-hold policy provided, and staff stated the policy is not typically given out upon discharge.
Failure to Send Required Transfer Documentation: Facility staff did not provide required transfer/discharge paperwork to the receiving hospital for three residents. One resident with stroke history, dysphagia, diabetes, and psychiatric diagnoses had two acute transfers with no documentation showing what information was sent, and two other residents with significant medical and cognitive conditions also had no evidence that the required face sheet, med list, labs, radiology, or other clinical information was provided with the transfer packet. The DON acknowledged the missing documentation, and the facility policy required these materials to be printed and placed in the transfer envelope.
A resident with multiple comorbidities and intact cognition was discharged home with physician orders for a bedside commode, front‑wheeled walker, and HH services including nursing and PT. The resident reported that the ordered DME did not arrive for several days and HH services did not start for about a week, leaving her to use a bedpan despite limited mobility and reporting increased weakness and flaccidity in one leg. The Director of Social Services and Director of Rehabilitation confirmed the delays in DME delivery and HH initiation, and the Administrator acknowledged the time frames were not acceptable. Discharge planning notes documented the resident’s complaints about missing DME, the inability of a PCA company to provide services, and subsequent contacts with the DME supplier and multiple HH agencies, confirming that the resident’s ordered equipment and HH services were not provided in a timely manner after discharge.
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