The facility failed to provide complete transfer documentation for two residents sent to an acute care facility. The Interact Hospital Transfer Form did not include advanced directives or a medication list with last administration times, and the Acute Care Transfer Document Checklist was left unmarked; progress notes also did not show what was sent to the receiving provider.
The facility failed to notify the LTC Ombudsman and the resident/resident representative of two residents’ transfers and did not provide complete bed-hold notification documentation. One resident lacked decision-making capacity and was transferred after being found unresponsive with abnormal VS and swelling; the other resident had capacity and was transferred after slurred speech, lethargy, twitching, pallor, and severe hypotension. Surveyors found missing proof of ombudsman notification and incomplete bed-hold notice documentation.
The facility failed to provide written transfer notices for two residents who were sent to the hospital for altered mental status. No notice forms were found in the EHRs, and the Administrator stated the facility does not do that, even though the notices were to include the reason for transfer, appeal rights, how to appeal, and Ombudsman contact info.
A resident had multiple acute transfers, and after losing capacity to make her own medical decisions, she was transferred again following a fall. Although she received a transfer notice and bed hold notice, the resident's designated representative or POA was not informed in writing of the reason for the transfer/discharge and did not receive the bed hold notice after the change in capacity.
Failure to Provide Transfer, Ombudsman, and Bed-Hold Notices: The facility failed to provide required written transfer/discharge notices and bed-hold documentation for two residents transferred to acute care. One resident had capacity and was transferred after a fall with a subsequent femur fracture surgery; the other lacked capacity and was also transferred to acute care. In both cases, the facility sent medical information to the hospital, but did not issue the required transfer/discharge notice to the resident or representative, did not notify the State LTC Ombudsman, and had incomplete bed-hold authorization documentation.
A resident was discharged to a motel with home health services, a wheelchair, medications, and a follow‑up medical appointment arranged, and received education on medications, blood glucose monitoring, emergency response, and home health services. Discharge planning discussions and a referral to the Take Me Home program were documented, and the facility agreed to pay for an initial period of the motel stay. However, record review and staff interviews confirmed that the resident was not given the required 30‑day written discharge notice prior to leaving, limiting the resident’s ability to prepare for discharge and exercise discharge‑related rights.
A resident was transferred to the hospital, and the EMR contained no evidence that a written bed hold notice was provided to the resident or the resident’s representative. The Administrator acknowledged the facility could not produce evidence that the notice had been given.
Failure to Notify Ombudsman of Resident Transfer: A resident was transferred to the hospital, but the facility did not send the Notice of Transfer/Discharge form to the LTC Ombudsman and had no record that the Ombudsman was notified of the hospitalization. The SW confirmed the paperwork had been overlooked before surveyor intervention.
A facility failed to verify that a bed hold notice was given to a resident or the resident’s legal representative when the resident was transferred to an acute care facility for SOB with hypoxemia. The resident had decision-making capacity, but the medical record contained no bed hold notice, and the notice later provided by the NHA was not signed by the resident. The NHA acknowledged that a signature should have been obtained or verbal consent documented.
Surveyors found that discharged residents were not given written information about their right to appeal discharge or how to contact the Ombudsman or State Agency. Review of discharge paperwork for three discharged residents showed no documentation of appeal rights or related contact information. The DON confirmed that this information was not included in the discharge documents, and the Administrator acknowledged the issue during the survey exit.
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