Failure to Notify Ombudsman of Hospitalizations, Discharges, and Transfers: Social services did not send the required monthly notices to the LTC Ombudsman regarding resident hospitalizations, discharges, and transfers. The ombudsman reported receiving no notices for 2025 or 2026, and the administrator confirmed the notices had not been sent for over a year. The facility policy reviewed did not address the process for ombudsman notification.
Failure to complete a bed hold for a resident after hospital admission. A resident with emphysema, heart disease, CHF, DM, dysphagia, and CKD became increasingly fatigued and weak, was taken to the clinic by family, and was later admitted to acute care for pneumonia. The facility received notice of the hospitalization, but there was no indication a bed hold was completed verbally or in writing, despite policy stating residents leaving for hospitalization and choosing to return were to complete a bed hold.
Failure to notify the Ombudsman of a resident discharge occurred when a resident with intact cognition, a walker, and diagnoses including CHF and COPD was sent to the hospital after worsening COVID-related respiratory symptoms, including cough, wheezing, and SOB. The SSD said she was responsible for the notice but missed this discharge, and the DON stated all discharges were expected to be reported and that a backup plan should have been in place.
A resident with intact cognition, ADL assistance needs, COPD, and chronic respiratory failure was transferred to the ED and hospitalized three times for respiratory issues. The record lacked evidence that staff provided or documented bed-hold rights information, including the option to reserve the bed and any applicable costs for this private pay resident, and SW staff could not locate documentation of any bed-hold discussion.
A resident with impaired cognition, hemiplegia, diabetes, and anxiety was transferred to the ER for diarrhea, but the facility did not provide or document a written transfer notice or bed-hold notice. The RN said he believed he left a message with the guardian but did not document it, and the DON verified the EMR lacked the required forms and follow-up.
A resident with schizophrenia, intact cognition, and independence in ADLs was involuntarily discharged for alleged non-compliance with facility policy and the facility’s inability to meet needs, but the discharge summary did not specify the policy involved, the unmet needs, the resident’s self-care limitations, the discharge destination, or any post-discharge appointments. The medical record lacked a recapitulation of stay and medication reconciliation, despite facility policy requiring detailed clinical and functional discharge information. Staff interviews indicated that administrative staff issued a discharge notice when the resident returned from jail, that typical practice is to arrange a safe discharge with community supports, and that the social services designee had not completed the discharge summary. The DON confirmed the discharge was involuntary, and the administrator acknowledged the resident did not receive all information required under federal regulations.
Failure to notify the LTC Ombudsman of hospitalizations and a discharge: two residents had documented hospital/transfer events, but progress notes and the facility’s monthly ombudsman notice did not show required communication. One resident had moderate cognitive impairment, used a walker, and needed assistance with multiple ADLs; the other had moderately impaired cognition, significant ADL dependence, and diagnoses including hip fracture, CAD, HF, HTN, and DM. Social services staff acknowledged the ombudsman notifications were behind and that one resident’s discharge had not been coordinated with the ombudsman.
Two residents with complex medical and behavioral histories received 30‑day discharge notices that lacked required contact information for the LTC ombudsman and the state agency appeals coordinator. One resident, a smoker with liver disease, COPD, and mental health diagnoses, was repeatedly observed smoking in his room despite education on facility policy and was issued a discharge notice with an incorrect transfer date and no ombudsman details; he believed he was being discharged for being mean to others and had to obtain the ombudsman’s number from staff. Another resident with DM, chronic pain, opioid dependence, depression, and anxiety, identified as a vulnerable adult due to substance abuse and trauma, was discharged after being found using illicit drugs and sent to the hospital, but his notice also omitted ombudsman and appeal contact information, leaving him thinking his only option was to beg the administrator to stay. The ADON acknowledged the omissions, and the LTC ombudsman reported that notices should include this information and that there was a delay in receiving copies of the notices.
A resident was transferred to the ED due to safety concerns, but neither the resident nor their family received a written notice of transfer or information about the facility's bed hold policy. The EMR lacked documentation of these notifications, and staff interviews confirmed that only verbal notice was typically provided, with no written policy in place or uploaded to the record.
A resident with multiple chronic conditions left the facility against medical advice without a comprehensive discharge plan or proper documentation of education regarding the risks of leaving AMA. The facility did not provide a discharge summary or recapitulation of stay at the time of discharge, and key information such as medication instructions and follow-up care was not given to the resident.
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