A resident with respiratory failure, HTN, and anxiety became SOB and diaphoretic, received a breathing tx, and was sent by EMS to the hospital. The facility could not locate the required SNF/NF to Hospital Transfer form or other transfer records showing what information was communicated to the receiving provider.
Failure to Provide Transfer/Discharge Notices and Bed-Hold Documentation: The facility did not ensure that two residents received proper transfer/discharge notices and/or bed-hold offers after hospital transfers. One resident’s transfer/discharge notice was left blank for the resident or representative, and another resident’s record showed no documentation of a bed-hold offer and no resident/representative signature on the notice, despite the resident being able to make needs known and having multiple chronic conditions.
Failure to Offer Bed Holds and Provide Transfer Notices: The facility did not offer bed holds or provide written transfer notices to the resident or Ombudsman for multiple residents sent to the hospital or ER. Residents with COPD, CHF, diabetes, kidney disease, heart disease, and hypothyroidism were transferred and returned, but the EHR lacked documentation that bed holds were offered or that transfer/discharge forms were completed and provided as required.
Missing Transfer and Bed-Hold Notices: The facility failed to provide Nursing Home Transfer/Discharge Notices and bed hold notices for 4 sampled residents transferred to the hospital. The residents had diagnoses including dementia, Alzheimer's disease, AFib, HF, diabetes, and a traumatic subdural hemorrhage, and staff stated transfer packets should include the notice and bed hold, but the records reviewed did not contain the required documentation.
Failure to notify the Ombudsman of hospital transfers and an AMA discharge. Three residents with severe cognitive impairment were transferred to the hospital, but the EHR had no documentation that the Ombudsman was notified. A resident with moderate cognitive impairment was discharged AMA, and the resident was omitted from the Ombudsman discharge report because AMA residents were not included.
Failure to Send Transfer/Discharge Notices to Ombudsman: The facility did not provide the required copy of the transfer/discharge notice to the State LTC Ombudsman for two residents who were hospitalized. The MDS records showed both residents were admitted to the facility and later discharged to an acute hospital, and the Medical Records Director acknowledged the notices were not sent even though the facility policy required sending them.
Failure to complete discharge and transfer documentation: A resident who left AMA had no documentation of provider notification, discharge summary, medication or oxygen arrangements, home health services, or PCP follow-up scheduling. In addition, multiple residents transferred to the hospital had no documented nurse-to-nurse report to the receiving facility, and some had no documented bed hold offer or written transfer notice. Staff interviews confirmed the missing documentation.
The facility failed to provide a written bed-hold notice for one resident and failed to send transfer/discharge notices to the LTC Ombudsman for two residents. One resident with MS and diabetes was hospitalized for a UTI, and another resident with respiratory and heart failure discharged home AMA; records did not show the required notices were completed.
Surveyors found that the facility failed to ensure effective discharge planning for two residents, including coordination with community agencies and medication management. The discharge policy lacked guidance on pre-discharge needs such as medication ordering, medication teaching, arranging home care services, equipment, and follow-up appointments. One resident with diabetes and dementia was discharged home with family caregivers but without documented medication teaching or scheduled follow-up, and the community case manager was not notified, preventing caregiver scheduling and leaving the family without insulin administration training. Another resident with cognitive impairment and prior documented safety concerns at home was discharged without in-home care ordered, medication refills sent, or a follow-up physician appointment arranged, and the resident later returned after not receiving care and running out of medications. The SSD reported not handling medication re-ordering or teaching and typically not making follow-up appointments, while leadership staff acknowledged they were unaware of the lack of discharge coordination.
Failure to provide required transfer/discharge and bed-hold documentation. The facility did not give written notice to residents or representatives, did not notify the Ombudsman, and did not document that required info was sent to the receiving provider for multiple residents transferred to acute care or discharged AMA. Staff reported bed-hold info was given verbally and transfer/discharge forms were not completed for all discharges.
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