A resident with chronic respiratory failure and intact cognition was transferred twice to hospitals, including an out-of-state facility for acute on chronic hypoxic respiratory failure, acute hypercapnic respiratory failure, and sepsis. Review of the EMR and interviews with the ADON showed there was no written transfer notice, no documentation that bed-hold and readmission policies were provided, and no required hospital transfer paperwork, despite facility policy requiring these actions for emergency transfers. This lack of required documentation and notification caused the resident worry, fear, and frustration and contributed to a delay in readmission after a prolonged hospitalization.
A resident with muscle weakness and chronic pain syndrome was transferred to the hospital, but the record did not show written bed hold notice was provided at the time of transfer. The NHA and DON reported that the nurse caring for the resident had not given the required notice.
The facility failed to complete a discharge medication reconciliation for one resident discharged with home health services, with the discharge summary lacking a physician’s order listing and resident signatures. The facility also failed to provide written transfer notification for another resident sent to the hospital ED; staff stated they only sent bed-hold information instead of the required transfer notice.
Missing Bed Hold Documentation for Residents Transferred to ED: The facility failed to provide and document bed hold information for three residents who were transferred to the ED. EMR review showed blank bed hold paperwork and no record that the information was given to the resident and/or representative during hospital transfers. The SSD confirmed the bed hold information was not provided or scanned into the EMR.
Failure to provide written transfer notices and bed hold info for 3 residents. Three residents were transferred to the ED, but the transfer forms lacked signed receipt acknowledgement and did not include the facility bed hold policy. A social services designee confirmed the notices were not provided in writing and stated she was unaware the transfer notification needed to be given in writing.
A resident with severe cognitive impairment, dementia, and significant behavioral symptoms was transferred emergently to a hospital after assaultive behavior toward staff, and when EMS later attempted to return the resident, nursing staff informed EMS and the hospital that the resident would not be accepted back due to aggressive and combative behavior. The resident’s spouse, identified as the responsible party and POA, was verbally told by a nurse that the resident would not be readmitted, but there was no evidence that a written transfer/discharge notice, bed-hold information, or appeal rights (FIT-100/ITD-100) were provided to the representative, nor that a written copy was sent to the Ombudsman. Review of the transfer checklist showed the regulatory notice items and second nurse witness signature were not completed, the Ombudsman information on the form was outdated, and the facility’s bed-hold policy contained obsolete regulatory references.
A resident with severe cognitive impairment, multiple chronic conditions, and dependence in ADLs experienced a decline in condition leading to an emergency hospital transfer. The family had previously reported concerns about a non-functioning call light and inadequate means for the resident to summon help. On the day of transfer, the family member questioned the change in the resident’s condition and whether he should go to the hospital, but later learned from the hospital—not the facility—that he had been transferred. The LPN involved gave inconsistent statements about whether the provider, the resident’s representative, and the hospital received appropriate notifications and transfer/discharge paperwork. Record review showed no documentation that the provider was notified of the change in condition, that the resident or representative received the bed-hold policy or transfer/discharge paperwork, or that the family was informed of the transfer.
The facility failed to send the Ombudsman a copy of the notice of transfer or discharge for two residents. One resident with heart failure was transferred to a hospital, and another resident with weakness was admitted and discharged home the same day. Staff interviews showed confusion about who was responsible for sending the monthly transfer/discharge list to the Ombudsman.
Failure to provide written bed hold notice at hospital transfer. A cognitively intact resident with diagnoses including bile duct obstruction and weakness was transferred to the ER for evaluation and treatment of excessive purulent drainage from a biliary drain, then sent to another hospital for treatment and admission. The EMR did not show written notice of the facility's bed hold policy, and the DON stated the resident was not given the notice when transferred; the policy required the notice at admission and again with emergency transfer.
A resident with dementia, agitation, and a progressive neurologic disorder experienced increasing agitation, exit-seeking, and physical aggression, leading to transfer to a hospital after attempts at redirection and provider contact. Review of the EMR showed the resident’s orders and care plans were later discontinued and the resident was no longer in the facility, but there was no documentation that a written transfer notice or the facility’s bed-hold policy was provided to the resident or representative. The DON confirmed that such notices were expected at the time of transfer but could not locate any evidence that the responsible party received written notification of the transfer or bed-hold policy.
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