A resident with HTN, COPD, hyperlipidemia, and renal insufficiency was discharged to an inpatient rehab facility, but the chart did not contain a discharge summary. The resident had moderately impaired cognition with a BIMS score of 10, and MDS staff confirmed that no discharge summary had been completed.
A resident was discharged home with hospice services without a completed discharge summary or notification to the State Ombudsman office. Record review showed that, although a discharge return-not anticipated assessment documented the admission and discharge, the clinical record contained no discharge summary and no evidence of Ombudsman notification. An LPN reported the resident left with medications and personal belongings. The DON stated discharge summaries should be completed by the MDS coordinator and filed in the record but confirmed none was present for this resident. The administrator, who is responsible for notifying the Ombudsman, acknowledged that the Ombudsman was not notified and stated they only provide such notification for involuntary discharges.
A resident with traumatic brain injury, mood disorder, and intact cognition exhibited escalating behaviors including yelling, cursing, hoarding medications, attempting self-harm, threatening staff, and expressing suicidal intent, leading to an emergency discharge and police transport to a hospital. An immediate written discharge notice was completed and given to the resident, but the LPN who prepared the transfer packet sent only a face sheet, diagnosis list, and medication list, omitting the discharge notice. The administrator had assumed all discharge documents were sent, and the hospital case manager later confirmed the hospital did not receive the discharge notice until they contacted the facility about returning the resident, showing the facility failed to provide the required immediate written discharge notice to the receiving hospital.
The facility failed to provide required written notices of transfer or discharge to residents or their representatives prior to transfers. The facility’s transfer/discharge policy did not include the requirement for written notification, and a resident sent to an acute care hospital for behaviors did not receive written notice before being transferred. An LPN reported never having heard of or provided written transfer notices, and the DON stated they were unaware of the requirement and confirmed that such notices had not been given, despite multiple resident discharges in the preceding months.
A cognitively intact resident with osteomyelitis and a methicillin susceptible staphylococcus infection was discharged to a hospital for a short-term stay and reported not receiving information about the facility’s bed hold policy at the time of transfer. The facility’s written policy required that residents be given notice of the bed hold option whenever they were hospitalized or on other leave. Staff interviews revealed inconsistent understanding of who was responsible for providing the bed hold notice, with an LPN indicating it was the case manager’s role and another LPN stating it was the sending nurse’s responsibility. The ADON reported that provision of the bed hold policy should be documented in the nurse’s notes, but there was no documentation that the policy was given to this resident at the time of discharge.
A resident with intact cognition was transferred to a hospital for evaluation and treatment of seizure-like activity, high blood pressure, and elevated pulse, but did not receive the required written notice of transfer. The facility’s policy required written notice when practicable before transfer, including in urgent situations. Documentation showed the resident was sent to the hospital and a family member was notified, and the resident later confirmed the hospitalization. In an interview, the DON described the paperwork typically sent with residents but did not include a written transfer notice and acknowledged that staff did not provide such notice for this transfer and that they were unaware of the requirement.
The facility did not provide written notices of transfer to residents or their representatives when residents were sent to the hospital for acute medical issues. Staff interviews confirmed that written notices were not given, and the facility's policy did not include this requirement. Multiple staff members, including the ADON, interim DON, and an LPN, were unaware of the need to provide such notices, and a review of records showed no evidence of compliance.
The facility did not provide required written notices of transfer to residents or their representatives before transferring three residents to an acute care hospital. Transfers occurred for reasons including aggressive behavior, decreased oxygen saturation, and physical discomfort, but in each instance, the DON confirmed that no written notification was given.
Surveyors found that the facility did not provide copies of its bed-hold policy to two residents when they were transferred to the hospital, including one with severe cognitive impairment and another with moderate cognitive impairment who was hospitalized for acute cystitis. Documentation showed the residents were sent to the ER and one was later readmitted, but there was no record of bed-hold policy notification at the time of transfer. An LPN stated they did not give residents the bed-hold policy when sending them to the hospital, and the DON confirmed that the policy was only reviewed at admission and not reissued during subsequent hospital transfers.
A resident with end stage renal disease, who was cognitively intact, was transferred to the hospital without being provided notification of the facility's bed hold policy at the time of transfer. Staff interviews indicated confusion about who was responsible for this notification, and the administrator confirmed that such information was only given at admission, not during transfers.
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