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.
Surveyors found that the facility did not notify the State Long-Term Care Ombudsman of a discharge for a resident with Alzheimer’s dementia and epilepsy whose spouse chose to take the resident home. Policy requires that written discharge notice, including reasons for the move, be provided to the resident and representative and that a copy be sent to the Ombudsman. Record review showed no documentation of Ombudsman notification, and the DON confirmed that such documentation was absent, creating the potential for adverse outcomes including the need for an advocate when the Ombudsman was not notified.
A resident with Down Syndrome and chronic respiratory failure with hypoxia experienced involuntary movements and extreme labored breathing, received O2, and was transferred to the hospital by EMS. Review of the medical record showed no documentation that the required written bed-hold notice specifying the duration of the bed-hold policy was provided to the resident or the resident’s representative at the time of transfer, and an RN confirmed she could not locate any such documentation. This deficiency was identified for one of three records reviewed and was determined to create the potential for psychosocial distress if the resident could not return after hospitalization.
Surveyors found that the facility failed to document that required pertinent health information, including care plan goals and advance directive details, was provided to hospitals when multiple residents were transferred for issues such as falls with head injuries, lacerations, respiratory problems, altered mental status, chest pain, and gastrointestinal symptoms. Although eINTERACT transfer forms were completed in the EHR, the residents’ records did not show that this critical information accompanied them to the receiving facilities, contrary to the facility’s discharge and transfer policy.
The facility did not provide required written bed-hold policy notifications to three hospitalized residents or their representatives. One resident with dementia, heart disease, and DM was hospitalized, and the Admissions Director acknowledged speaking with the POA but not providing a bed-hold document. Another resident with hemiplegia, hemiparesis, COPD, ESRD, depression, bipolar disorder, and anxiety, and a third resident with UTI, DM, heart failure, and CKD were also hospitalized, yet their records contained no documentation of bed-hold notifications. The Administrator confirmed there was no record of such notifications for these two residents.
Surveyors found that the facility did not follow its own discharge and bed-hold policy requiring written notice of transfer, reasons for the move, and bed-hold information before hospital transfers. Record review showed that two residents with complex medical conditions, including stage IV pressure ulcers, diabetes, spinal cord injury, cancer, hypertension, and lumbar spinal stenosis, were transferred to the hospital without any documented Notice of Transfer or Bed Hold Policy in their charts. In an interview, the DON confirmed that the facility did not have the required transfer and bed-hold documentation for these residents.
A resident with acute respiratory failure, pneumonia, and COPD experienced worsening respiratory status, did not respond to an albuterol treatment, and required transfer for a higher level of care. Although a transfer/discharge notice and bed-hold agreement were completed, the record lacked documentation that required information was sent to the receiving provider, including practitioner contact details, resident representative contact information, advance directive status, special instructions or precautions for ongoing care, and comprehensive care plan goals. The DON and CRN confirmed that this required transfer documentation was not present in the medical record.
A resident with multiple chronic conditions, including diabetes, heart failure, and cirrhosis, was transferred twice to the ER without documented provision of the required written Notice of Transfer and bed-hold policy. Facility policies required written notice of transfer, with specified exceptions for urgent medical needs, and written information on bed-hold policies prior to and upon transfer for hospitalizations or therapeutic leave. Record review and an RN interview confirmed that no such documentation could be found for these transfers, resulting in a deficiency related to resident rights and notification.
A resident with bipolar disorder, obstructive sleep apnea, and personal care needs, identified as an independent smoker, was educated on the facility’s smoking policy and informed that noncompliance would result in a 30-day written discharge notice. After the resident smoked on facility grounds, staff documented that a 30-day notice was issued, but there was no evidence that this notice was provided in writing as required by facility policy and regulation. The resident then requested to leave AMA, and while the record contained a discharge assessment and an AMA risk acknowledgment, it lacked documentation of the required written 30-day discharge notice, which the Administrator and Resource Nurse later confirmed they could not produce.
Surveyors found that the facility did not provide a required bed-hold notice to a resident or the resident’s representative at the time of a hospital transfer. The resident, who had multiple behavioral health diagnoses including paranoid schizophrenia and anxiety, was transferred to the hospital and later returned, but the facility’s bed-hold documentation was not completed for this episode. During interview, the Administrator confirmed that the bed-hold notice was not provided at the time of transfer, despite the requirement to do so.
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