A resident with tracheostomy status, COPD, and acute/chronic respiratory failure, who required scheduled trach suctioning and nebulizer treatments, was discharged home without essential respiratory DME, specifically a suction machine and nebulizer. Although social services arranged some DME (hospital bed, wheelchair, bedside commode) and home health services, there was no evidence that suction or nebulizer equipment was ordered or delivery verified, despite facility policy requiring confirmation of all needed DME before discharge. After discharge, the resident lacked correct tracheostomy supplies at home, EMS was called to perform suctioning, and the resident was subsequently hospitalized. Interviews with the resident’s representative, social services, home health nurses, and the administrator confirmed that the suction machine was not included in the DME arrangements and that required equipment had not been ensured prior to discharge.
Failure to Notify Resident Representatives of Hospital Transfers and Bed-Hold Rights: Two residents were transferred to the hospital, but the facility did not notify the resident representative or provide the bed-hold policy in a timely manner. One resident had CHF and was sent out for elevated BNP and tachycardia, and the record showed no transfer notice or bed-hold information was sent. For another resident, the bed-hold agreement was completed days after the transfer. The AR clerk confirmed the omissions, and the Administrator stated transfer notifications and bed-hold letters should be sent for all hospital transfers.
A resident with severe cognitive impairment and a history of wandering was discharged after going on therapeutic leave with family, but neither the resident nor their representative received a required bed-hold notice or clear communication about discharge status, appeal rights, or the process for returning. Facility staff confirmed that bed-hold notifications were not provided for therapeutic leave, and the resident's family experienced confusion regarding medication, discharge, and the removal of a wander guard.
A resident with a history of cerebral infarction was transferred to the emergency room, but the facility did not provide the required written transfer notice to the resident's representative. The Administrator confirmed that no written notification was sent, as the resident returned within a few hours and staff did not think it was necessary.
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