Two residents were transferred to other SNFs without receiving the required 30-day written notice and without clear evidence of consent or proper discharge orders. In one case, a resident was moved the day after receiving notice, the discharge form lacked the resident’s signature, the resident reported never signing any forms and being told abruptly to pack and leave, and record review showed no MD order for discharge. In the other case, a resident’s daughter/POA reported she was told transfer was only a possibility, was not called back before the move, and later learned the resident was already on the bus; she also reported missing belongings and that the resident was unprepared and unaware the move was permanent. Facility leadership acknowledged that same-day notice was used when a resident was considered agreeable and that a verbal MD order for transfer had been given, despite a written policy requiring interdisciplinary discharge planning and prior review of the discharge plan and proposed date with the resident or representative.
A resident was transferred to a hospital for evaluation and treatment of a right hip concern after the attending practitioner directed staff to send the resident to the closest hospital, and non-emergent transport was arranged with the resident’s family in agreement. Although a transfer/discharge notice and a hospital transfer form were completed, surveyors found no documentation that the required written bed-hold notice—detailing the state bed-hold policy, any reserve bed payment policy, and the facility’s bed-hold and return policies—was provided at or before the time of transfer. In interviews, an LPN/medical records staff member acknowledged that the bed-hold notice “must not have been done,” and the DON stated that floor nurses or unit managers are responsible for completing bed-hold forms and obtaining family signatures when present, confirming that this process was not followed for this hospitalization.
A resident admitted with post-amputation orthopedic aftercare, osteomyelitis of the left ankle and foot, COPD, and muscle weakness was discharged without required discharge documentation. Record review showed no AHCA discharge/transfer form, no documented discharge notifications or reason for discharge, no discharge summary, and no post-discharge plan of care, despite facility policy requiring these elements. The SSD confirmed the absence of appeal and discharge documentation, and the NHA acknowledged that social services staff responsible for discharge planning and resident notification had not completed the required assessments and notes.
A resident with end stage renal disease who required regular dialysis was discharged without the facility notifying the dialysis center of the discharge or the need to transfer services, resulting in a missed dialysis session. Staff interviews revealed confusion about responsibility for this communication, despite facility policy assigning this duty to social services.
The facility did not provide written notification to residents and their representatives regarding transfers to the hospital, instead giving all transfer documents to EMS and only verbally informing residents of the reason and destination. Multiple LPNs and the DON confirmed this practice, and clinical records lacked documentation of written notification.
A resident with multiple chronic conditions was discharged without receiving the required written notice detailing the reason, date, and location of discharge, appeal rights, or Ombudsman contact information. The facility also failed to send a copy of the discharge notice to the Ombudsman office, and the discharge summary lacked essential documentation such as medications, follow-up appointments, and therapy summaries.
A resident with multiple medical conditions was discharged without a complete written discharge summary or medication list, and key sections of the discharge documentation were left blank. The resident's designated representative was not notified in advance, and there was no evidence that discharge instructions or medications were provided. Staff interviews confirmed the discharge process was not properly followed, and required documentation and communication were lacking.
The facility did not ensure that two residents and their representatives received proper documentation and notification regarding transfer or discharge. For one resident with severe cognitive impairment and multiple mental health diagnoses, there was no record of notification or the required transfer/discharge notice when transferred to the hospital. For another resident with cardiac and vascular conditions, discharge documentation was incomplete and unsigned, and there was no evidence that the required notice or discharge information was provided.
A resident with intact cognition was transferred to the hospital for evaluation and treatment without receiving written notification about bed-hold options or appeal rights prior to the transfer. The required transfer and discharge notice form was incomplete and dated after the resident's return, and staff interviews confirmed that the necessary documentation and notifications were not provided at the time of transfer.
The facility did not provide required transfer and discharge notifications to the local LTC Ombudsman for three residents, as confirmed by record review and staff interviews. The Social Services Director, responsible for sending these notices, could not provide evidence that notifications were sent, and the facility's policy requiring timely notification was not followed.
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