The facility failed to provide written bed-hold policy notice to two residents or their representatives during hospital transfers. One resident had HTN, kidney disease, and hypokalemia, and another had hyperlipidemia, CHF, and a right femur fracture; records showed hospital transfers, but no documentation that the required bed-hold information was given at the time of transfer.
The facility failed to notify the State Ombudsman of emergency transfers for four residents. One resident was sent out after a painful, red incision-line lump and later admitted with cellulitis, another after 911 was called for crushing chest pain and later admitted with CHF exacerbation, a third was admitted with osteomyelitis, and a fourth was transferred for respiratory distress, hypoxia, and cyanosis and later admitted with respiratory failure with hypoxia. Records did not show the required ombudsman notification, and an E5 confirmed the residents were not on the list sent to the ombudsman.
Surveyors found that the facility failed to document required communication of care plan goals, advance directives, and other essential information to a receiving provider for a resident sent to the hospital and expected to return, and also failed to provide written notice of its bed-hold policy to three residents or their representatives at the time of hospital transfers. Clinical records for residents with conditions such as hypertension, BPH, muscle wasting, muscle weakness, hyperlipidemia, and trigeminal neuralgia lacked evidence of written bed-hold notifications, and the DON confirmed these omissions during interview.
Surveyors found that the facility failed to provide and document required written notices explaining the reasons for hospital transfers for multiple residents. In several cases, a resident had falls resulting in fractures, stroke‑like symptoms, respiratory changes, or positive blood cultures leading to transfer and hospital admission for conditions such as sepsis, bacteremia, atrial fibrillation, UTI, stroke, and a femoral neck fracture. These residents were often cognitively impaired, required extensive ADL assistance, and had complex medical histories including dementia, post‑CVA hemiplegia/hemiparesis, indwelling catheters, feeding tubes, and pressure ulcers. Despite physician orders for transfer and subsequent hospital admissions, the clinical records did not contain written notifications to the residents or their representatives describing the reasons for the transfers, and the NHA confirmed that written transfer letters were not being completed.
A resident with multiple chronic conditions and a complex medication regimen was discharged home without being provided a complete written list of current medications and instructions. Although nursing documentation stated the resident was educated on all discharge orders and medications and that all medications were sent home, the discharge paperwork only listed a limited subset of prescribed drugs, omitting several ongoing medications such as anticoagulants, cardiac medications, anticonvulsants, and supplements. The DON later confirmed there was no documentation that a full and accurate medication list with instructions was given to the resident or family at discharge.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
Failure to communicate required transfer information for three residents. Three residents were transferred to outside care settings, but their records lacked documentation that the facility sent required clinical details to the receiving provider, including physician contact information, resident representative contact information, advance directive information, special instructions or precautions, care plan goals, and other necessary information. During interview, the DON and NHA could not provide evidence that the information had been communicated.
Failure to Provide Transfer Information and Bed-Hold Notice: The DON confirmed that multiple residents transferred to the hospital had records lacking evidence that required clinical information was sent to the receiving provider and that the resident and/or representative received the written bed-hold policy notice. The affected residents had diagnoses including COPD, CHF, CKD, GERD, dialysis dependence, diabetes, dementia, and other significant conditions, but the charting did not show the required transfer documentation or bed-hold disclosure.
Failure to notify resident representatives in writing of hospital transfers and provide required bed-hold notices was identified for four residents. One resident was sent out after coughing following intake, another after a wound began bleeding heavily, a third after a fall from a mechanical lift with injury, and a fourth after becoming unresponsive; in each case, there was no documented written notice to the representative or ombudsman, and the SW stated she did not notify them and was unaware she was supposed to.
Surveyors found that the facility did not follow its own transfer and bed-hold policies for a resident who was sent to the hospital. The resident, who had HTN, anxiety, and diabetes, was transferred to an acute-care provider without documented communication of key information such as care plan goals, advance directives, specific care instructions, representative contact information, and other details needed to meet the resident’s needs. The record also lacked written notice to the resident or representative about the facility’s bed-hold policy at the time of transfer. The DON confirmed these failures, which violated resident rights requirements.
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