A cognitively intact resident with an established goal of community discharge was sent home after active discharge planning and education on medication administration, but no written transfer or discharge notice was documented or provided, and no copy was sent to the Regional Ombudsman. The Ombudsman reported not receiving any transfer or discharge notices since the prior SW left, and interviews with former and current administrative, social services, and medical records staff showed that responsibilities for preparing and sending discharge notices were unclear and that no one recalled issuing or transmitting a notice for this resident.
The facility failed to send the Ombudsman copies of required Notices of Transfer/Discharge for three residents who were discharged to an assisted living facility, discharged home, or transferred to a hospital for acute care. Instead of forwarding the actual notices on the date they were issued, staff emailed periodic Admit/Discharge Reports that only listed resident names, discharge dates, and destinations. The Social Worker, DON, and Administrator all reported they believed these summary reports met the requirement, despite prior education from the Ombudsman that copies of all transfer/discharge notices for all discharges and emergency transfers must be provided.
A resident with intact cognition was discharged to the community without a complete discharge summary that recapitulated the course of treatment. The electronic Transfer/Discharge Report contained basic demographic and clinical data but left key sections blank, including advanced directives, diet type/texture/fluid consistency, and resident-specific information on behaviors, ambulation, bladder/bowel status, feeding, and usual level of functioning, and lacked a signed acknowledgment that a copy was provided to the resident or representative. The SW reported she arranged post-discharge services, provided a medication list and satisfaction survey, and documented discharge arrangements, but was unaware that a comprehensive discharge summary with a recapitulation of the stay was required, and the Administrator confirmed the form used did not include this required summary with interdisciplinary input.
A resident with a history of stroke-related hemiplegia, hemiparesis, and a right tibial fracture was prepared for discharge to an assisted living facility with a goal of returning to the community. The facility’s Discharge Planner altered the resident’s FL2 form by changing ambulatory status and striking three medications, but these changes were not reviewed or signed by a provider. The Assisted Living Executive Director, having previously rescinded a bed offer due to an FL2 indicating non-ambulatory status, refused admission when the corrected but unsigned FL2 was received in the parking lot at the time of attempted admission. As a result, the resident, who reported being able to transfer with a cane and use a wheelchair for distance, was transported back and readmitted to the facility the same day.
The facility failed to provide required written notices of hospital transfer, including reasons for the transfers, to four residents and/or their responsible parties. In each case, residents were transferred for issues such as shortness of breath, abdominal pain, falls, and altered mental status and were later readmitted, but the medical records contained no documentation of written transfer notices. Staff, including a unit manager and social workers, reported that clinical documents and the bed-hold policy were sent with residents and that responsible parties were notified by phone, yet they were unaware of any requirement or designated responsibility for issuing written notices. The administrator also stated she was not aware that written notification of hospital transfers was required.
The facility failed to provide and document required written transfer/discharge notices and bed-hold policy information for multiple residents sent to the hospital. A cognitively intact resident who was her own RR had two hospital transfers without documented written notice of the reason for transfer, and for one transfer there was no documented bed-hold policy; she reported not receiving either written notice or the policy. Another resident with moderately impaired cognition was transferred without documented written notice or bed-hold policy, and the RR confirmed not receiving them. A third cognitively intact resident was transferred for planned surgery; the RR reported receiving written transfer notice but not the bed-hold policy, and the DON acknowledged emailing about the surgery but not the policy. Staff interviews revealed confusion between the Social Worker, Business Office Manager, and Administrator regarding who was responsible for issuing written transfer/discharge notices and mailing the bed-hold policy, and the facility could not explain the missing notices and documentation.
The facility failed to provide required written notification to the Ombudsman for emergency hospital transfers involving two residents who were sent out for evaluation and treatment of chest pain, seizures, and seizure-like activity, with one resident not returning after transfer. Record review showed no documentation of Ombudsman notification for any of these transfers, and interviews revealed that the Social Worker had not sent any emergency transfer notifications and was unclear about responsibility for this task, while the Ombudsman reported no such notifications had been received for several months and the Administrator believed the Social Worker was responsible.
A resident with end-stage COPD, who was on oxygen therapy, sustained burns after smoking while on oxygen and required EMS transfer to the hospital. The incident and subsequent change in condition were not documented in the medical record, as confirmed by the nurse on duty and the facility administrator.
Two residents and their responsible parties were not provided with required information about the facility's bed hold policy during hospital transfers. Medical records lacked documentation of this notification, and interviews with the responsible parties and the Admission Director confirmed that the policy was not discussed or provided at the time of transfer.
Two residents with cognitive and medical impairments were transferred to the hospital without receiving required bed hold notices. Staff interviews revealed that neither the charge nurse nor the admission coordinator provided these notifications, and the administrator confirmed that such notices should have been given at the time of transfer.
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