A resident with a traumatic lower-leg amputation who used a wheelchair was transferred to an Independent Living Facility (ILF) after facility staff verbally represented to the ILF that the resident was totally independent and walked with a walker. The ILF, which had only minimal staff and could not provide physical care or assist with ADLs, received no clinical documentation beyond a face sheet and reported that it could not accommodate a wheelchair user. Facility staff later acknowledged there was a miscommunication and that they had not clearly communicated the resident’s ongoing need for a wheelchair, despite a policy requiring that all necessary information and special instructions be shared to ensure a safe and effective transition of care.
A resident with CHF was transferred to the ED after developing SOB, low O2 sat, and edema, but the facility had no documented evidence that a written bed-hold notification was given to the resident or his representative at the time of transfer. The BOM confirmed there was no record of a Bed Reservation Notification or other documentation showing the resident and/or representative were informed of bed-hold rights.
A resident being discharged for non-payment did not receive a complete and timely 30‑day transfer/discharge notice, and the State LTC Ombudsman was not notified as required. The initial notice listed the same day as the effective discharge date, omitted the discharge destination, and was not copied to the Ombudsman. The resident reported not receiving a copy of the 30‑day notice. Staff confirmed that the Ombudsman was not notified when the initial notice was issued and that the facility’s practice was to fax notices on the day of discharge. After a board‑and‑care destination was identified, an updated notice including the location was created but not signed by the resident until the day of discharge, and it was faxed to the Ombudsman shortly before the resident left. Facility policy requires that notices include the specific destination, be given at least 30 days in advance, be sent to the Ombudsman at the same time as to the resident, and that significant changes such as a new destination trigger a new notice and reset of the 30‑day period.
Failure to Document Hospital Transfer Reports: Two residents were transferred to a GACH, but their charts did not contain transfer report documentation. One resident had a change in condition with pain, weakness, lethargy, and a fall-related transfer order; the other had poor intake, swallowing difficulty, and a transfer order to the hospital. Nursing notes showed both residents left the facility, but the records lacked the required transfer packet, report details, and related documentation referenced by the DON and facility policy.
Missing discharge notice and summary: A resident with cataract, HTN, and COPD was discharged to a lower level of care, but the medical record did not contain a Notice of Proposed Transfer or a discharge summary. The SSD stated the notice was used to inform the resident of the appeal process and to notify the Ombudsman, and the DON confirmed the discharge summary was absent. The facility P&P required written transfer/discharge notice with appeal rights and a discharge summary for community discharge.
Incomplete discharge paperwork for a resident lacked required details across the Discharge Summary, Post Discharge Plan of Care, and Transfer/Discharge Report. The SSD did not document confirmation of placement in the EMR, and RN and DON review found missing items such as the receiving board and care location/address, prognosis, IDT representative, resident address, mental/social status, DME, safety instructions, and responsible party information.
A resident with multiple chronic conditions, including NSTEMI, DM2, Alzheimer’s disease, and dementia with behavioral disturbance, was transferred to a hospital after a fall and later moved to another hospital. The facility sent an initial Notice of Transfer to the LTC Ombudsman listing only the first hospital and did not update it when the resident was moved. When the facility decided not to readmit the resident, staff informed the hospital that a higher level of care was needed but did not complete or provide a required Notice of Discharge to the resident or representative, did not send a copy to the LTC Ombudsman, and had no physician assessment or documentation in the EHR supporting the determination that a higher level of care was required, contrary to facility policy and stated discharge procedures.
A resident with a history of T7–T8 compression fracture, HTN, muscle weakness, and capacity for medical decision-making was discharged home without complete discharge documentation. The facility’s discharge instruction/recapitulation form lacked entries for SNF therapy services received, medication education and reconciliation (including a current med list and next provider), social services and activities (dental, vision, hearing, speech, cognition, activities), emergency contact information, current medical diagnoses, functional status, and discharge-day assessments (skin, lungs, abdomen, bowel, urinary status). Although the form was checked to indicate that discharge information and a pharmacy discharge med summary were sent with the resident, the facility could not produce documentation or a copy showing the resident’s current medication list or actual discharge meds, despite active orders for multiple meds including antihypertensives and anticoagulants. The DON confirmed the discharge documentation and assessments were incomplete and that no record of the discharge medication list existed.
Failure to Provide Written Bed-Hold Notice: The facility did not ensure that two residents or their representatives received timely written notice of the bed-hold policy before hospital transfer. One resident was cognitively intact with DM, hemiplegia, and ESRD, and the other was cognitively impaired with dementia and CKD; both bed-hold notices reflected telephone notification to family instead of written notice, despite the DON stating the notice should be provided in writing.
Two residents with multiple chronic conditions, including dementia, chronic pain, respiratory failure, CKD, CHF, and other comorbidities, were transferred to a hospital/ER for changes in condition, including uncontrolled pain, altered mental status, unresponsiveness, and panicked rapid breathing. In both cases, the facility did not provide written bed-hold notices to the residents or their responsible parties at the time of transfer, despite facility policy requiring written information on bed-hold policies at admission and again at transfer (or within 24 hours for emergency transfers). The DSD acknowledged that bed-hold information was only given verbally by phone, and the DON confirmed there was no documentation in either resident’s record that written bed-hold notices were provided.
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