A resident with severe cognitive impairment and significant psychiatric and behavioral diagnoses exhibited escalating verbal and physical aggression, leading to emergency transfer to a behavioral hospital. Although staff had previously discussed behavior concerns with the resident’s representative, the record shows no 30‑day notice of facility‑initiated discharge was issued, and no notice of transfer or discharge with appeal rights or attached bed‑hold policy was provided to the representative at the time of transfer or afterward. Documentation reflects that only the resident, not the representative, received the bed‑hold policy despite the resident’s confusion, and there were no subsequent facility notes of communication with the representative or the psychiatric facility. The Administrator and DON later acknowledged that the required 30‑day notice and transfer/discharge and bed‑hold notices were not provided, and the representative reported she never received any paperwork or appeal information.
Surveyors found that the facility failed to properly notify emergency contacts about the bed-hold policy for two residents who were transferred to the hospital. One cognitively intact resident with chronic kidney disease, diabetes, and a seizure disorder signed a bed-hold notification declining to hold the bed, but the resident’s emergency contact, who was also the durable power of attorney, was not notified when the resident became unresponsive and was sent to the hospital. Another resident with severe cognitive impairment, atrial fibrillation, lumbar fracture, wound dehiscence, and malnutrition was transferred to the hospital, and although the bed-hold policy was sent with EMTs and the emergency contact was informed of the transfer, there was no documentation that the emergency contact was informed of the bed-hold policy, even though the resident signed a form declining bed hold. No written facility policy on bed-hold notification was available for review.
Two residents with complex respiratory and cardiac conditions were transferred to the hospital—one for altered mental status and one after becoming unresponsive following administration of lorazepam and oxycodone-acetaminophen—without documented review of the required written transfer/discharge notice and bed-hold policy with them or their representatives. In one case, the record showed notification of the representative and hospital but no evidence that the notice and policy were reviewed; in the other, a form was completed and signed by the Social Services Director indicating the resident was unable to sign, yet there was no documentation that the information was reviewed with the resident or representative. Staff interviews and record review confirmed that the required written notification process, as outlined in facility policy, was not documented for these hospital transfers.
Failure to Provide Transfer/Discharge Notice and Bed Hold Policy: A resident with liver cancer, altered mental status, and malnutrition was sent to the ER after being found lethargic and difficult to rouse, then admitted to the hospital. The record lacked documentation that the resident or representative received written transfer/discharge notice and the bed hold policy, and the notice provided during survey did not include the bed hold policy.
A resident with COPD, dementia, a legal guardian, and an active DNR order was transferred to the hospital for shortness of breath, but the transfer form listed CPR status and identified the wrong resident representative as notified. The guardian said the facility called the nephew instead of her, and hospital staff later told her they had been informed the resident was full code. No copy of the transfer packet sent with the resident was provided.
The facility failed to consistently provide and document required bed-hold policy notices when several residents were transferred to the hospital. In multiple cases, residents with dementia, psychotic disorders, COPD, chronic respiratory failure, altered mental status, and cerebral infarction were sent out for acute changes in condition, and while transfer notes reflected physician and family notifications, they lacked documentation that the bed-hold policy was discussed with the resident or responsible party. Notices of Transfer or Discharge often indicated a copy of the bed-hold policy was sent with the resident, but the records did not show signed and dated acknowledgment by the resident or appropriate representative, including in situations where a resident had moderate cognitive impairment, short-term memory issues, or a documented need for a proxy and a financial POA authorizing an agent for health care decisions.
The facility failed to notify the State LTC Ombudsman of discharges for three residents, as required by its transfer and discharge policy and state regulation. One resident was discharged home with a spouse after an extended hospital stay, another was transported to a local ER and discharged per the census and billing records, and a third was discharged home with no anticipated return. The SSD reported she typically submitted a monthly list of discharges to the Ombudsman, first by email and later via a state website, but she missed the list for one month, had been ill during that period, and did not document Ombudsman notification in the residents’ records or maintain proof of submission.
Failure to Document Bed Hold Notifications: The facility did not provide or document bed hold notices for two residents with repeated hospital transfers. One resident had DM, lung disease, and stroke, and the other had CP, malnutrition, and constipation. Records lacked transfer forms or progress note evidence that bed hold notices were discussed or given, and staff reported keeping copies in a binder without signatures or proof of receipt.
Surveyors found that the facility did not provide or document required written transfer/discharge notices and bed-hold policy information for four residents who were sent to the hospital, including individuals with conditions such as dementia, CHF, chronic respiratory failure, and CKD. In each case, progress notes showed that the resident was transferred for acute issues, but the clinical records lacked evidence that written notices were given to the residents or their representatives, and in one case lacked documentation that required information was sent to the receiving provider. Facility leadership, including the ADON, DON, and Administrator, acknowledged that the records did not contain the required documentation, despite a written policy requiring such notices and information exchange.
Surveyors found that the facility failed to notify the Ombudsman and provide required bed-hold notices when two residents with dementia-related diagnoses and other conditions were transferred to the ER. In one case, a resident with dysphasia, dementia, and anxiety was sent to the ER per NP orders without any documented Ombudsman notification or bed-hold notice to the resident or representative. In another case, a resident with Pick’s disease, aphasia, and repeated falls was found on the floor with a head laceration, assessed, and sent by ambulance to the ER, with the DON, physician, and family notified, but again without Ombudsman notification or a bed-hold notice to the resident or representative. The DON reported that the Social Worker did not notify the Ombudsman and that bed-hold information was not provided to residents or families.
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