Missing transfer, bed-hold, and Ombudsman notifications: The facility did not document required transfer/discharge notices or bed-hold information for several residents who were discharged home or sent to the hospital, including residents with hospice care, POAHC involvement, and repeated hospital transfers. The NHA stated the Business Office was not completing Ombudsman notifications, and the facility could not produce evidence that the Ombudsman was notified or that the required notices were provided.
Written bed hold notices were not completed for four residents who were transferred or hospitalized. Records for the residents did not contain the required bed hold documentation, and the DON/CNO and NHA confirmed there were no bed holds for those transfers. A SW stated the notice should accompany the transfer paperwork and a copy should remain in the resident record.
Failure to notify the Ombudsman of resident hospital transfers. The facility did not include several residents on monthly transfer notices, and records showed multiple hospital transfers with no documentation that the Ombudsman was informed. An SW stated the submitted lists were accurate but could not locate the residents on the documentation.
Failure to Provide Written Transfer Notices: The facility did not provide written transfer notices for multiple residents who were sent to the hospital. Records showed hospital transfers and, in some cases, signed bed hold notices or Ombudsman notification, but no written notice with the reason for transfer, Ombudsman contact information, or appeal rights. The DON and medical records staff stated they were unaware the notice was required for residents or next of kin.
A resident with schizophrenia, diabetes, carcinoma of the scalp, obesity, and moderately impaired cognition was protectively placed in the facility under court-appointed guardianship. The facility discharged the resident home without written consent from the Guardian and without notifying the court or APS before discharge; APS was notified only after the discharge, and the NHA verified the required notification and consent were not obtained.
Bed-Hold Notices and Ombudsman Notifications Not Consistently Provided: The facility did not provide written bed hold notices to residents’ representatives when residents were transferred to the hospital, and it did not consistently notify the State LTC Ombudsman of resident transfers/discharges. A resident with impaired cognition and two residents with intact cognition were hospitalized for conditions including anemia, thrombocytopenia, COVID, urinary stones, and severe head/neck pain; records showed phone confirmation for bed holds, but written notice to representatives was not provided in some cases and Ombudsman notification was missed for multiple monthly reporting periods.
Missing discharge documentation and transfer/bed-hold notices: A resident who left after a phone discharge order had no recapitulation of stay, no signed AMA paperwork, no signed discharge order, and no documentation that education or services were offered before discharge. Two other cognitively intact residents were transferred to the hospital, but the facility had no written transfer or bed-hold notices for those events, and the NHA confirmed the notices were not provided.
Failure to communicate reason for ED transfer: A resident with multiple diagnoses, including dementia, CHF, COPD, CKD, and DM2, was sent to the ED after an unresponsive episode. The record documented the resident was unresponsive but breathing, with the POA updated, yet there was no documentation that the facility communicated the reason for transfer to the ED. The DON stated the hospital was notified of another unresponsive episode, but no record of the communication was found.
Missing discharge, transfer, and bed-hold documentation: The facility did not complete required Ombudsman notifications for several residents’ discharges and hospital transfers, and one resident’s bed hold and transfer notice could not be found. Records showed one resident was cognitively impaired at discharge, another was cognitively intact, and a third had multiple acute hospital transfers for vomiting, abnormal vital signs, aspiration, and an NSTEMI, yet the required notices were absent from the EHR or not completed.
A resident with a recent below-knee amputation and intact cognition was sent to the hospital multiple times for wound drainage, edema and SOB, and unresponsiveness with hypoglycemia. The record contained no bed hold or transfer notice for any of the transfers, and the DON and NHA could not locate the documentation.
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