Surveyors determined that the facility did not send the required transfer notice to the State LTC Ombudsman when a resident with vascular dementia, post-stroke sequelae, constipation, and atrial fibrillation—who had documented memory impairment, behavioral symptoms, and dependence for toileting and transfers—was sent to the hospital via ambulance. A nursing note recorded the transfer, but there was no documentation that the Ombudsman was notified. During interviews, the Director of Social Services and the Assistant Administrator stated that Ombudsman notifications for hospitalizations and discharges were usually emailed in batches and acknowledged that no email notification for this transfer could be located, characterizing the omission as an oversight.
Missing Ombudsman Notifications and Bed Hold Policy Notices: The facility did not document sending transfer/discharge notices to the State LTC Ombudsman for several residents who were sent to the hospital, and it did not provide bed hold policy notices to resident representatives when residents were transferred or hospitalized. A resident with dementia and psychotic disturbance, a resident with dementia, HTN, and DM, and another resident with dementia, BPH, and HTN were all transferred without documented Ombudsman notification or bed hold policy notice; another hospitalized resident also did not receive a bed hold policy notice.
The facility did not complete or send required transfer/discharge notices to residents, their representatives, or the Ombudsman for three residents who left the facility. One resident was sent to the hospital by EMS for abdominal pain and distention, another discharged AMA after a family discussion, and a third was taken to the hospital after a reported fall and hip refracture. An Ombudsman email confirmed missing discharge notifications, and an AA stated the notices had not been sent because there was no Social Worker.
Surveyors found that the facility did not send required copies of transfer/discharge notices to the State LTC Ombudsman for two residents who were transferred to the hospital, one with a hip fracture and dementia and another with dementia and breast cancer experiencing uncontrolled pain and later hospice planning. Although transfer/discharge forms and bed-hold documents were completed and kept in a binder, the Director of Social Work acknowledged that no copies or monthly transfer/discharge lists had been sent to the Ombudsman for several months, and the Ombudsman confirmed not receiving notices or monthly lists during that period.
The facility failed to follow required transfer/discharge procedures for three residents with dementia, bipolar disorder, depression, anxiety, and polyneuropathy by not providing timely, complete written notices to them, their representatives, and the State LTC Ombudsman. One cognitively intact resident with dementia and diabetes was moved to a locked unit without documented wandering assessments, without a completed discharge plan, and without a signed notice or timely notification to the representative. Another cognitively intact resident with dementia and bipolar disorder was discharged with a notice dated one day before discharge and no resident signature. A third resident with moderate cognitive impairment reported staff packed and moved them without prior notice; documentation showed a late-entry note stating the resident was notified and given discharge paperwork upon discharge, and the discharge notice used "verbal consent" instead of the resident’s signature. The Ombudsman reported not receiving discharge notices for these moves and stated the facility had been using outdated forms that did not meet current regulatory requirements, while the Administrator acknowledged only issuing 30-day notices when residents were discontent with leaving.
A resident with significant care needs was discharged without all necessary information being sent to the home care agency, resulting in a delay in the initiation of home care services. The facility did not provide required documentation such as demographics and orders, causing the agency to be unable to process and start services as expected.
A resident was discharged without documented evidence of a 30-day written notice, bed hold notification, or ombudsman notification, and there was no record of discussions regarding discharge planning or post-discharge care arrangements. The facility also failed to document communication with the resident's MLTC provider for assessment of additional home care hours, resulting in incomplete discharge documentation.
Surveyors found that the facility did not provide required written notifications of transfer or discharge, including bed-hold policies and ombudsman notification, for two residents who were hospitalized. In both cases, there was no documentation of discharge notices or bed-hold notifications in the medical records, and one resident's family was not informed by the facility about the hospitalization.
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