Failure to Provide Written Transfer/Discharge Notice: The facility did not provide written transfer/discharge documentation to a resident or the resident’s rep after a hospital transfer. The resident had multiple diagnoses including respiratory failure, AFib, dysphagia, vascular dementia, and a stage II heel pressure ulcer, and was transferred for altered mental status and increased confusion before returning to the facility. The required notice, including appeal rights and bed-hold information, was not found in the EMR or the Admissions Coordinator’s file.
A resident with a history of respiratory failure, who had been receiving supplemental O2 in the facility, was discharged home without discharge paperwork or supplemental O2. The responsible party had informed staff in advance of the planned discharge and was told paperwork would be ready, but when they arrived, no discharge documents were available and attempts by nursing staff to obtain them were unsuccessful. The resident left without discharge instructions, and the SW later confirmed that although the resident had received supplemental O2 in the facility, no O2 order was sent home. Discharge instructions were instead reviewed with the responsible party by phone several days after the resident had already left.
The facility did not notify the Ombudsman of the discharge of two residents who were transferred to a hospital for care that could not be provided at the facility. Although internal procedures assigned responsibility for notification to the Social Worker, the Ombudsman's office reported not receiving any transfer or discharge reports from the facility for several months.
A resident and their representative were not given a written bed hold notice that included the required current per diem rate when the resident was transferred to a hospital. Although the bed hold policy and rate changes were reviewed at admission and mailed to representatives, the specific rate was not included on the notice at the time of transfer, leaving the resident without all necessary information.
The facility did not provide required bed-hold notifications to two residents or their representatives during hospitalizations, as confirmed by record reviews and staff interviews. Documentation of bed-hold notifications was missing, and staff were unclear about the process and responsibilities, resulting in residents and their representatives not being informed of their rights and policies related to bed-hold status.
Two residents who were transferred to the hospital did not receive the required written transfer notices, as confirmed by review of their electronic medical records and an interview with the Administrator, who stated the facility was not aware of the requirement to send such notices.
Self-audit
Pick a level of detail and, optionally, what to focus on — then generate a survey-ready checklist distilled from the most recent citations.
Beta · AI-generated — for reference only, not professional advice. Verify against current CMS guidance before relying on it. Assisto accepts no responsibility for how this checklist is used.
Citations used to create this checklist
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Get More From Your Search Results
Create an account to access advanced search filters, save your searches, and get unlimited access to detailed Plan of Corrections.
Create an Account