The facility failed to timely notify the Ombudsman of resident transfers and discharges. Record review showed multiple months in which notices were not sent, and for one resident transferred to the hospital, the Ombudsman notification was delayed until months later. The DON confirmed the late notification and stated an action plan was in place.
A resident was discharged to the hospital, but the medical record lacked required discharge documentation, including the change of condition, discharge location, medical summary, disposition of personal effects, and disposition of medications. The Administrator and SW stated police were involved, and the SW believed the resident was transferred to a local hospital, but no discharge paperwork was found and the discharge process was not followed.
A resident was transferred to the hospital for abdominal pain, but no transfer form was found in the record. The facility's policy required a transfer form with key clinical and contact information, and the DON confirmed that no form was sent to the receiving hospital and no documentation showed the required information was conveyed.
The facility did not document that required transfer information was sent to the hospital for two residents who were transferred out for acute care. One resident was sent for SOB related to bronchitis and pneumonia, and another was sent after a fall with hematoma. The Interim DON said the facility’s process is to send the face sheet, advance directives, physician orders, and MAR, but the chart did not show what information was actually transmitted.
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.
A resident was discharged home, but chart review showed no documentation that the Ombudsman was notified of the discharge. The Administrator acknowledged the social worker did not complete the notification because they were unaware it was required.
Failure to Provide Transfer Notices and Ombudsman Notification: The facility did not document written transfer notices with appeal rights and LTC Ombudsman contact information for residents transferred to the hospital due to abnormal vital signs. The DON stated the notices were not provided to the resident or resident representative, and there was no documentation that the Ombudsman was notified for multiple hospital transfers.
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.
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