A resident with bipolar disorder, dementia, and anxiety, who was independent in ADLs but care planned as an elopement risk, was allowed to go on LOA with a friend after the conservator consented. Nursing late entries documented the LOA, the resident’s failure to return, multiple unsuccessful attempts to contact involved parties, notification of police and clinical leadership, and discovery that most belongings were gone, while the census showed the resident as discharged. However, the Director of Social Services did not document the LOA outcome or the discharge in the clinical record and did not submit the required discharge notification to the State LTC Ombudsman portal, stating unawareness that non-return from LOA constituted a discharge, despite a facility policy requiring detailed discharge documentation.
A resident with acute respiratory failure, septic shock, intact cognition, and high ADL assistance needs was discharged home with documentation stating that skilled home care services (nursing, PT, OT, and HHA) had been arranged. Post-discharge, the listed home care agency reported having no record of the resident and not serving the resident’s geographic area, and another RN from the agency confirmed no referral was received. The DNS acknowledged the resident should have had home care but was unsure about service start timing or agency coverage, and the SW confirmed that no home care services were provided and could not explain why a referral was not made or confirmed, contrary to the facility’s own transfer and discharge policy.
The facility failed to provide timely notification to the State LTC Ombudsman when several residents with complex medical and behavioral conditions were discharged or planned for discharge. Although 30‑day Notices of Intent to Discharge were issued and discharge planning meetings were documented, the facility did not upload the required discharge notices to the Aging and Disability Services portal at the same time notices were given to residents and their representatives. In one case, a resident on an independent LOA later died in the ED, and no discharge notice was uploaded because staff considered it a transfer. For the other residents, uploads to the portal occurred days to over a month after the written discharge notices, and interviews with facility staff revealed they were unaware of a specific timeframe for notifying the ombudsman, contrary to CMS requirements and the facility’s own transfer/discharge policy.
Failure to notify the Ombudsman of resident hospital transfers. Four residents with diagnoses including Parkinson's disease, schizophrenia, diabetes, and pleural effusion were transferred or sent to the hospital, but the facility could not provide documentation that the Ombudsman was notified. The SW confirmed the monthly transfer-to-hospital forms were not sent for the reviewed period, and the DON was unaware the notifications were not being completed.
The facility failed to provide required written notice of bed-hold rights to two residents or their responsible parties when they were transferred to the hospital for acute medical issues, including confusion after a fall and vomiting coffee-ground emesis with abdominal tenderness. Record reviews showed no documentation that bed-hold options were communicated at the time of hospitalization, despite a facility policy directing that such notices be given upon discharge to the hospital and maintained in the resident’s record. Interviews revealed that social workers did not issue bed-hold forms for hospital transfers and believed this was the responsibility of business office or admissions staff, while the Regional Business Office Manager acknowledged that the forms were missing and should have been provided.
Delayed Ombudsman Notification for Transfers and AMA Discharge: The facility did not timely notify the State LTC Ombudsman when a resident with epilepsy, TBI, and acute embolism was transferred to the hospital, when a resident with CHF, CKD, and bladder cancer had two hospitalizations, or when a resident with low back pain, DM, pneumonia, and gait abnormalities left AMA. The record also lacked timely nursing documentation of the AMA departure and notification of the resident representative, and the monthly discharge/transfer lists were submitted late.
Failure to notify the Ombudsman office of resident transfers and discharges. A resident with acute respiratory failure with hypoxia, acute kidney failure, hypertension, and moderate cognitive impairment was discharged home with family, but the SW did not routinely submit required monthly discharge notifications and believed the portal was only for AMA, abuse, or inappropriate situations. The admin stated the SW was responsible for the notifications, while the regional ombudsman confirmed the facility had portal access and should have been aware of the updated reporting requirements.
Failure to Notify Ombudsman of Transfer/Discharge: A resident with COPD, dementia, spinal stenosis, and severe cognitive impairment fell, sustained a head laceration, and was sent to the hospital before returning with sutures in place. The SW and DNS stated that social services were responsible for Ombudsman notification, but the required transfer/discharge notice was not sent because the SW lacked portal access.
A resident with diabetes, anxiety, depression, and mobility issues, who was cognitively intact and independent, did not have a timely or documented discharge plan despite an active discharge goal and referral to a community program. The care plan lacked discharge planning details, and there was no evidence of follow-up on referrals or alternative discharge options, contrary to facility policy.
A resident with dementia and other conditions was transferred to the hospital after elopement, but the facility failed to provide timely bed hold and discharge notices to the resident and responsible party, did not complete a discharge summary, and refused to readmit the resident when ready for return. The facility also backdated the discharge notice and did not follow required consultative or appeal processes, as confirmed by interviews with the conservator, hospital social worker, and ombudsman.
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