A resident with obesity, a T-11 to T-12 SCI, multiple rib fractures, and a dislocated elbow was discharged to another SNF, but the facility did not provide recent information about a non-injury fall and an abuse-related sexual behavior allegation. Staff acknowledged no verbal report was given before discharge, and the receiving facility reported the resident arrived without authorization, report, or orders.
Failure to Provide Bed Hold and Transfer/Discharge Notices: The facility did not document providing bed hold notices for four residents who were transferred or discharged to the hospital, including one resident who was unresponsive at transfer. The facility also did not document a written transfer/discharge notice for one resident. Staff interviews and record review confirmed the notices were not found in the EHR, despite facility policy requiring written notice of bed-hold rights and appeal rights when a resident is transferred or discharged.
Failure to Provide Written Discharge Notice and Discharge Planning: A resident admitted for rehab after sepsis, falls, gait impairment, and confusion had no documented discharge plan or discharge goals in the care plan. Although skilled coverage ended and the resident appealed the termination, staff stated they usually notified residents verbally and the EHR did not contain a completed written transfer/discharge notice with appeal rights. The resident’s rep said they were rushed to find an AFH and felt the resident was not ready to leave.
Failure to Provide Written Transfer/Discharge and Bed-Hold Notices: The facility did not provide written transfer/discharge and bed-hold notices for two residents reviewed. One resident’s guardian reported not receiving the discharge evaluation for review and signature, and another resident, who was severely cognitively impaired and had a guardian, was sent to the hospital with the notice completed in the chart but with no documentation that the guardian was contacted or given a written copy.
The facility failed to provide a written bed-hold notice to two residents at the time of hospital transfer. One resident was cognitively intact and said the facility did not discuss holding the bed after transfer for arm surgery, and the EHR had no documentation of a bed-hold notice or contact with the resident or rep. Another resident, who was alert and oriented, was transferred for vomiting, but the EHR also lacked documentation that the bed-hold policy was reviewed before or after transfer.
A facility failed to provide written transfer/discharge notices, bed-hold notices, and Ombudsman notifications for four residents transferred or discharged to the hospital. Records showed no completed transfer/discharge forms or bed-hold offers for residents with conditions including COPD, HF, pneumonia, and respiratory failure, and one resident reported not receiving a bed-hold notice or returning to the same room after hospitalization.
The facility failed to provide discharge instructions, assess home health or equipment needs, and arrange home medications for a resident who left AMA, with no discharge summary, instructions, or Notice of Transfer form documented. The facility also failed to provide written transfer notices for two residents sent to the hospital, and staff stated notices had not been provided for residents transferred to the hospital.
The facility failed to complete required NOTD and Ombudsman notifications for two residents who were emergently transferred to the hospital. EMR review showed no documentation of the transfer/discharge notice or Ombudsman notification, and staff interviews revealed confusion about who was responsible for the process for hospital transfers.
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 bed-hold notice at hospital transfer: The facility did not give written bed-hold information to two residents or their representatives when they were transferred to the hospital. One resident was alert and oriented and transferred for SOB related to bronchitis/pneumonia; the other was moderately cognitively impaired and said she was not told whether her bed would be held. Staff notes and EHR review showed no documentation of the required notice or contact.
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