The facility failed to provide a bed hold policy and written transfer notice when three residents were sent to the hospital. One resident had low O2 saturation and an elevated RR before EMS transfer, another was hospitalized for dehydration, sepsis, and failure to thrive, and a third was sent out for suspected infection. The medical record lacked documentation that the residents’ representatives received the required notices, and the representatives said they did not receive them. Staff said the transfer packet was supposed to include these documents, but they were not always completed, and the DON said the initiating nurse was responsible for issuing them.
The facility failed to provide required written discharge notices, including appeal rights and bed-hold information, to three residents who were dependent on staff for ADLs and were cognitively intact or impaired. As part of a unit reconfiguration to free up rehab beds, residents were told by phone they had to move within a short timeframe and were discharged to other SNFs without documented 30‑day or emergency discharge notices. Families reported they were not offered in‑house room alternatives, felt they had no choice, were not informed of appeal rights, and did not receive written discharge notices. Social workers reported they were directed by an administrator to move residents to open rehab beds and believed written notices were unnecessary for SNF‑to‑SNF transfers, resulting in discharges that did not comply with required notification standards.
Surveyors found that the facility did not provide or document required bed-hold policy information when residents were transferred to the hospital, despite the Administrator stating that floor nurses were responsible for giving this information at the time of transfer. Review of records showed multiple transfers and discharges with no corresponding bed-hold documentation. In addition, the facility failed to send required copies of discharge notices to the State LTC Ombudsman, even though its written policy required Ombudsman notification for facility-initiated discharges, planned discharges and transfers, and discharges decided while a resident was hospitalized. The last documented Ombudsman notification and transfer log were several months old, and the facility lacked copies of discharge notices for more recent discharges.
Missing Written Transfer and Bed-Hold Notices: The facility did not ensure written transfer notices and bed-hold information were provided for three residents sent to the hospital. Records showed each resident had acute medical issues such as COPD, respiratory failure, pneumonia, sepsis, or dementia, and staff documented emergency transfers or hospital admissions, but there was no documentation that written notices were given or mailed to the resident or representative. Interviews showed staff typically called family and sent clinical paperwork, but were not aware of written transfer notices being provided.
The facility did not follow its own bed-hold policy requiring written notice at the time of transfer for hospitalization. Record review showed that two residents who were discharged to the hospital did not have completed and signed bed-hold notices in their files, despite the policy requiring written notice specifying the bed-hold duration and return information and retention of a signed copy. In interviews, an LPN explained that the discharging nurse should fully complete the bed-hold form, including who was informed and the reason for discharge, and the Administrator stated he expected the notice to be given, completed, and signed before the resident left, but this did not occur for these transfers.
The facility did not provide required notifications to the State LTC Ombudsman regarding the transfer of a resident to the hospital due to respiratory distress and the discharge of another resident who was taken out by family. Review of records and staff interviews confirmed that no notifications were sent to the Ombudsman for any resident transfers or discharges over several months, and there was no documentation to support that such notifications occurred.
Facility staff did not obtain a physician's discharge order or provide a comprehensive discharge summary for a resident discharged to the community. The medical record lacked required documentation, including a summary of the resident's stay, treatment, and post-discharge care instructions, as well as a signed copy of the discharge summary. Staff interviews indicated a lack of awareness regarding follow-up resources and incomplete documentation of the discharge process.
A resident with complex psychiatric and medical needs was discharged without the facility providing the required 30-day written notice, bed hold policy, discharge summary, or reason for discharge to the court-appointed guardian. The facility also failed to provide a statement of appeal rights, Ombudsman contact information, and did not notify the Ombudsman of the discharge. Documentation and communication gaps were identified throughout the discharge process.
A resident with morbid obesity and complex care needs was transferred to a hospital without proper discharge documentation, reassessment, or a 30-day notice. The facility refused to readmit the resident after hospitalization, citing inability to meet care needs, and did not provide required notifications regarding appeal rights or bed-hold policies.
The facility failed to reassess and coordinate the return or alternative placement of three residents who were transferred to the hospital and later found to be medically stable and no longer a safety risk. Despite providing immediate discharge notices and required information to guardians and the ombudsman, the facility did not communicate or collaborate with hospital staff or guardians to facilitate the residents' return or alternative placement, and did not reassess the residents' needs after hospitalization.
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