Facility staff failed to provide required discharge instructions and documentation to two residents who left AMA. One resident with multiple acute and chronic conditions and moderate cognitive impairment left shortly after admission, and nursing notes only recorded that the resident left with family and signed AMA paperwork, with no evidence of discharge instructions or a recapitulation of the stay being provided, consistent with the DON’s statement that discharge summaries are not given for AMA discharges. Another resident with a hip fracture and intact to moderately impaired cognition was discharged by staff after the son arrived unexpectedly, with non‑narcotic medications provided but no documented discharge orders, and the receiving facility reported that it received only a face sheet and PASRR because the discharging facility stated it would not send additional records due to the AMA status, leaving the admitting facility without an H&P, clinical notes, or a medication list.
Facility staff failed to provide a resident and their representative with required written notice of discharge reasons and bed-hold options when the resident was sent to the hospital, and also did not document that clinical transfer information, including care plan goals and other key data, was sent to the receiving hospital. Although an LPN reported that her usual practice is to communicate critical information by phone and send printed clinical summaries with EMS, the resident’s record contained no evidence that the required bed-hold notice or continuity of care documents were provided for this transfer, contrary to facility policies on patient transfer and bed reserve.
Failure to Provide Written Transfer Notice: A resident was transferred to the hospital for fever, low O2, and a slow response, but the facility did not provide a written transfer notice to the resident, the resident representative, or the ombudsman. The DON/Social Services process described mailing notice to family, documenting it on a form, and sending weekly encrypted emails to the ombudsman, but no notice was found in the record or ombudsman binder.
Facility staff failed to notify the state LTC ombudsman of a resident transfer/discharge to a higher level of care. The resident had multiple serious diagnoses, including sepsis, CKD stage 3, AFib, malnutrition, and moderate cognitive impairment (BIMS 8/15), and was sent to the ER for Hgb 7 and severe abdominal pain. SW stated the transfer/discharge list was printed, but there was no evidence it was sent to the ombudsman.
Failure to Provide Written Transfer and Bed Hold Notices The facility did not provide written transfer notices and bed hold notices for several residents who were sent to the hospital. One resident was transferred after becoming extremely drowsy and altered from baseline, another called 911 for an ER transfer, a third was sent out after hypotension during dialysis, and a fourth was transported after staff found him slumped over and hard to arouse. Staff and leadership could not find documentation showing the required notices were given, and one resident stated she never received any paperwork related to the transfer or bed hold.
Facility staff discharged a resident with multiple chronic conditions and moderately impaired cognition to a group home without providing written notice to the court-appointed legal guardian, despite a court order granting the guardian authority over all placement decisions. The clinical record lacked a physician-documented rationale for discharge, a documented discharge plan, or evidence of guardian involvement or consent, and only contained social services notes referencing discussions with the resident and the group home. The discharge summary listed the group home address and claimed medication reconciliation was completed, but omitted several medications that a NP had documented should be continued for conditions such as CHF, diabetes, hyperlipidemia, vitamin deficiency, and prior cerebral infarction, and there was no clear evidence that discharge instructions were provided to the resident, representative, or receiving provider.
A resident with multiple comorbidities and intact cognition was discharged home with physician orders for a bedside commode, front‑wheeled walker, and HH services including nursing and PT. The resident reported that the ordered DME did not arrive for several days and HH services did not start for about a week, leaving her to use a bedpan despite limited mobility and reporting increased weakness and flaccidity in one leg. The Director of Social Services and Director of Rehabilitation confirmed the delays in DME delivery and HH initiation, and the Administrator acknowledged the time frames were not acceptable. Discharge planning notes documented the resident’s complaints about missing DME, the inability of a PCA company to provide services, and subsequent contacts with the DME supplier and multiple HH agencies, confirming that the resident’s ordered equipment and HH services were not provided in a timely manner after discharge.
A resident was discharged home with family, alert and oriented and without acute distress, but the facility did not notify the LTC ombudsman of the discharge. The DOSS stated she only sent monthly ombudsman notifications for residents transferred or discharged to the hospital and did not send notices for residents discharged or transferred elsewhere, saying she was not aware this was required.
Facility staff did not provide required written notices of transfer and bed hold policies to two residents and/or their representatives during hospital transfers. In both cases, although forms were completed or available, there was no evidence that the notices were actually sent or received, as confirmed by interviews with the director of social services and the social worker.
Facility staff did not provide a required bed hold notice to a resident during a hospital transfer and failed to send timely written notifications to a responsible party for two facility-initiated transfers. Documentation and staff interviews confirmed that these notifications were either missing or significantly delayed, contrary to facility policy and regulatory requirements.
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