Failure to Provide Timely and Proper Transfer/Discharge Notices to Residents, Representatives, and Ombudsman
Summary
The deficiency involves the facility’s failure to follow required transfer and discharge processes, including written notification to residents, their representatives, and the State Long-Term Care Ombudsman at least 30 days prior to transfer or discharge. The facility’s policy "Discharge Plan - Discharge Instructions" required that each resident with an anticipated discharge date receive necessary information and connections to outside services, and that each department interview the resident and continuing care provider to assess post-discharge needs and develop a plan. Despite this, three residents reviewed for transfer or discharge did not receive proper written notices or complete discharge planning consistent with regulatory requirements. Resident #3 had dementia, type II DM, and depression, and their MDS dated 10/13/2025 documented that they were cognitively intact, always understood, and always understood others, with no active discharge plan indicated. A single progress note by Social Worker #1 on 11/17/2025 stated that the representative had been informed the facility planned a lateral discharge to a more secure locked unit and that the resident would transfer to the first facility with an open bed. Social Worker #1 later stated the resident was discharged because they required a more secure unit due to dementia and wandering, but could not locate documentation of recent wandering behaviors or recent wandering/elopement assessments and could not recall who had reported the elopement risk. The transfer/discharge notice for this resident was dated 11/13/2025, cited that the resident’s needs could not be met at the facility, and indicated a lateral transfer to a secure locked unit, but the resident/representative signature line was blank, and there was no evidence the representative received written notice 30 days in advance. The nutritional section of the IDT discharge instructions dated 11/14/2025 for this resident was not completed. Resident #4 had dementia, bipolar disorder, and anxiety disorder, and their MDS dated 09/12/2025 documented that they were cognitively intact, always understood, and always understood others. This resident was discharged on 11/14/2025, and the discharge notice was completed and dated 11/13/2025 by Social Worker #1, but the resident signature line was blank, with no indication of written notice being provided 30 days prior to discharge. Resident #5 had polyneuropathy, bipolar disorder, and anxiety disorder, with an MDS dated 10/16/2025 showing they were usually understood, always understood others, and were moderately cognitively impaired. A late-entry progress note by Social Worker #1, effective 11/17/2025, documented that the resident was notified of discharge and given the discharge notice and summary upon discharge, although the resident had actually been discharged on 11/14/2025. The discharge notice for this resident was dated 11/13/2025 and the resident signature line was marked "Verbal Consent" instead of containing the resident’s signature. This resident later filed an appeal and was readmitted. In an interview, this resident stated staff did not tell them they were moving, that staff came into the room the morning of the move, packed them, and moved them, and that they had to beg to return. Interviews with facility staff and the Ombudsman further described failures in the notification process. Social Worker #1 stated they believed they spoke with Resident #3’s representative on 11/11/2025 about the planned discharge and allowed time for the representative to research two facilities, but did not call the representative prior to the actual move, despite the representative’s request to be notified so they could be present. Social Worker #1 acknowledged that the representative later complained about not being notified of the timing of the move and not receiving a written transfer/discharge notice. Social Worker #1 also stated they sent transfer/discharge notices to the Ombudsman and that three residents, including Residents #3, #4, and #5, were discharged to the same facility on 11/14/2025. However, the email to the Ombudsman with attached discharge transfer notices was dated 11/18/2025, after the transfers had occurred, and the Ombudsman reported they had not been receiving discharge notices from the facility and had only received one notice since July 2025. The Ombudsman stated that residents and their representatives should receive written notice 30 days prior to transfer or discharge and that the Ombudsman should receive a copy the same day, and also noted that the forms used by the facility prior to 11/17/2025 were outdated and did not meet current regulatory requirements. The Administrator stated that if a resident was agreeable to a move, the facility did not believe a 30-day transfer/discharge notice was required, and that if a resident was responsible for themselves, family would not need to be notified of a transfer. The Administrator also stated that they would only issue a 30-day transfer/discharge notice to a resident who was discontent with leaving the facility. The Ombudsman, who also served at the receiving facility, reported learning of the moves of four residents to the other facility after receiving calls from family members and the receiving facility that the residents were unhappy about the move. Overall, the record review and interviews showed that the facility did not provide timely, complete, and properly documented written transfer/discharge notices to the three residents and their representatives, nor did it send copies to the Ombudsman at least 30 days before the transfers or discharges, as required by 10 NYCRR 415.3(i)(1)(i–vii).
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Notify Ombudsman of Hospitalizations, Discharges, and Transfers: Social services did not send the required monthly notices to the LTC Ombudsman regarding resident hospitalizations, discharges, and transfers. The ombudsman reported receiving no notices for 2025 or 2026, and the administrator confirmed the notices had not been sent for over a year. The facility policy reviewed did not address the process for ombudsman notification.
The facility failed to provide written bed-hold policy notice to two residents or their representatives during hospital transfers. One resident had HTN, kidney disease, and hypokalemia, and another had hyperlipidemia, CHF, and a right femur fracture; records showed hospital transfers, but no documentation that the required bed-hold information was given at the time of transfer.
Two residents who experienced emergent hospital transfers for issues including abnormal critical labs, uncontrollable pain, and SOB with low O2 saturation were not provided with required written bed-hold policies and transfer notices. One resident had severely impaired cognition, and another was cognitively intact and later died at the hospital. Progress notes documented the transfers and that contacts or family were notified, but there was no documentation that written notices addressing bed-hold, appeal rights, or ombudsman information were given, despite facility policies requiring such written information at admission and again at or shortly after transfer. The Administrator confirmed that bed-hold notices were not sent for these residents.
Failure to Notify State LTC Ombudsman of Resident Discharge: The facility failed to send the required discharge notice to the State LTC Ombudsman for a resident who was discharged. The Ombudsman stated she never received the notification, the SW had no evidence of a report and was unaware of the monthly notification requirement, and the Administrator stated she did not know the rule. The resident had ischemic cardiomyopathy and a blank BIMS score.
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.
The facility failed to provide written transfer/discharge notices for three residents who were sent to the hospital, and for one resident it also failed to provide written bed-hold policy information. In one case, an LPN said she did not notify the guardian because she was the only nurse on the unit and did not have time, and there was no evidence that the Ombudsman was notified of the transfers.
Failure to Notify Ombudsman of Hospitalizations, Discharges, and Transfers
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman of resident hospitalizations, discharges, and transfers for calendar years 2025 and 2026. During interview, the ombudsman stated she had not received any hospitalization, discharge, or transfer notices for 2025 and none for 2026. Social services staff stated they were responsible for sending these notifications monthly and confirmed they were behind in submitting them. The administrator stated social services was responsible for the monthly notices, confirmed the notices had not been sent for over a year, and stated the ombudsman is a resource for residents if they feel they have been wrongly hospitalized, discharged, or transferred. A facility policy titled Discharge Planning dated 12/25 was reviewed and did not address the process for sending ombudsman notifications.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify the resident or the resident’s representative of its bed-hold policy for two hospital transfers. Facility policy stated that at the time of transfer for hospitalization or therapeutic leave, the facility would provide written notice explaining the duration of the bed-hold policy and information about the resident’s return to the next available bed, and that in an emergency transfer the notice would be provided within 24 hours. For Resident R24, who had diagnoses including high blood pressure, kidney disease, and hypokalemia, the record showed a hospital transfer on 3/31/26 and return on 4/5/26, but there was no documented evidence that written bed-hold information was provided at the time of transfer. For Closed Resident Record CR87, the record showed diagnoses including hyperlipidemia, congestive heart failure, and a right femur fracture. On 2/6/26, staff received venous doppler results indicating a nonocclusive thrombus in the right common femoral vein, relayed the results to the CRNP, and obtained orders to increase Eliquis temporarily and repeat an ultrasound. After the resident’s daughter called and staff reported the situation to the CRNP, the resident was sent to the hospital around 5:50 p.m. The emergency room transfer form and the clinical record did not include documented evidence that CR87 or the representative were provided written information about the facility’s bed-hold policy at the time of transfer.
Failure to Provide Required Bed-Hold and Transfer Notices for Hospital Transfers
Penalty
Summary
The deficiency involves the facility’s failure to provide required written bed-hold policies and transfer notices to two residents and/or their resident representatives when the residents were emergently transferred to the hospital. One resident had severely impaired cognition with a BIMS score of 3/15 and was transferred to the hospital due to abnormal critical lab results, then later returned to the facility. Documentation showed that the facility called the contact on file and a POA returned the call, but there was no documentation that a written transfer notice or bed-hold information was provided. The facility’s own policy required that written transfer/discharge notices include the reason for transfer, effective date, receiving location, a statement of the right to appeal, and contact information for the state LTC ombudsman and protection and advocacy agencies, as well as sending a copy to the ombudsman. A second resident, who had intact cognition with a BIMS score of 15/15, was transferred to the hospital on one occasion for uncontrollable pain and returned to the facility, and on another occasion for SOB, tremors in both arms, and oxygen saturation below 88%, after which the resident expired at the hospital. Progress notes documented the transfers and that the family was notified, but there was no documentation that written transfer notices or bed-hold policies were provided at either transfer. The facility’s bed-hold policy required that all residents or their representatives, regardless of payor source, receive written information about facility and state bed-hold policies twice: in advance of transfer (e.g., in the admission packet) and again at the time of transfer, or within 24 hours for emergency transfers. During an interview, the Administrator confirmed that bed-hold notices had not been sent for these two residents.
Failure to Notify State LTC Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to send a copy of Resident #8’s discharge notice to the representative of the Office of the State Long-Term Care Ombudsman before the resident was discharged. Resident #8’s nursing home discharge MDS assessment dated 04/13/2026 identified him as a [AGE]-year-old male admitted to the facility on [DATE], with an active diagnosis of ischemic cardiomyopathy and a blank BIMS score. During interview, the Ombudsman stated she had never received a discharge notification from the facility and said the facility was required to submit discharge notification every time it did an involuntary discharge, transfer, or presented discharge paperwork to a resident related to discharge. The Social Worker stated she had no evidence of a report to the state Ombudsman for Resident #8’s discharge and was not aware she was supposed to send discharge notification monthly. The Administrator stated she was unaware of the rule to notify the state Ombudsman of any resident discharges. Record review of the facility’s Transfer and discharge policy stated that a copy of the notice shall be provided to the representative of the Office of the State Long-Term Care Ombudsman and that the Social Services Director, or designee, shall provide notice of transfer via monthly list.
Missing Hospital Transfer Documentation
Penalty
Summary
The facility failed to ensure hospital transfer documentation was completed for one resident who was transferred to the hospital after complaining of not being able to breathe and appearing diaphoretic. The resident had diagnoses of respiratory failure, high blood pressure, and anxiety disorder, and was able to make needs known. A breathing treatment was provided, and the provider agreed to send the resident out for further evaluation, after which emergency transportation took the resident to the hospital. Record review found no documentation showing what information was provided or communicated to the receiving facility for the transfer. Staff stated that transfer documentation should have included a SNF/NF to Hospital Transfer form, the resident's face sheet, and the medication and treatment administration records, but they were unable to locate documentation showing these items were completed or sent for the resident's hospital transfer.
Failure to Provide Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The facility failed to provide a written notice of transfer/discharge before facility-initiated hospital transfers for 3 of 6 sampled residents (#6, #69, and #77). Medical record review showed resident #6 was transferred to the hospital and there was no evidence that a written transfer/discharge notice was issued to the resident or resident representative. There was also no evidence that a representative of the Office of the State Long-Term Care Ombudsman was notified of the transfer. The Regional Clinical Director confirmed there was no evidence the notice had been provided. Resident #69 was transferred to the hospital and the record showed no evidence that the facility issued a written transfer/discharge notice to the resident or the resident's guardian. An LPN stated she did not notify the guardian because she was the only nurse on the unit and did not have time, and she reported to the next shift that the guardian had not been notified. The guardian confirmed she had not been notified of the transfer. Resident #77 was transferred to the hospital and the record showed no evidence that the facility issued a written transfer/discharge notice or written information on the bed-hold policy to the resident or resident representative, and there was no evidence that the Ombudsman was notified of the transfer. The Regional Clinical Director confirmed there was no evidence the bed-hold and transfer/discharge notices were provided.
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