The facility failed to provide the required written transfer notice to residents or their RRs after emergent hospital transfers for two residents. One resident was transferred after extreme agitation and ineffective PRN medication, and another was transferred after lethargy and severe hypotension with 911 transport to the ED. The Consultant Admin stated transfer notice forms were not being sent to residents or families, and the DON stated the notice should be provided when a discharge occurred.
Failure to provide bed hold and transfer notices after hospital transfers for three cognitively intact residents. One resident was transferred after a fall and later for increased behaviors, another was sent out after becoming unresponsive, and a third was sent out for a change in condition; in each case, the required notice was not given to the resident or RR in a timely manner, and one notice was sent to the Ombudsman instead of the resident.
A facility failed to include the bed hold reserve payment amount in written emergency transfer notices for 3 residents who were hospitalized. The transfer letters stated that each resident was entitled to a 10-day bed-hold privilege, but they did not list the reserve payment amount and also referenced insurance the facility did not participate in. One resident had DM and HF, another had orthopedic aftercare and a humerus fracture, and a third had AFib and hypertensive heart disease with HF.
Surveyors identified that the facility failed to properly document and communicate required information during acute transfers and discharges for two residents. In one case, NTACF forms lacked resident representative details and did not include bed-hold or reserve payment information. In another case, a discharge summary was missing the resident or representative's signature, lacked evidence of communication, and contained outdated vital signs, with no physician discharge order documented.
A resident with multiple medical conditions and severe cognitive impairment was discharged without a required discharge summary being completed by the responsible LPN. The facility's policy mandates documentation of discharge in the medical record and communication to the receiving provider, but this was not followed, as confirmed by staff interviews and review of the resident's records.
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