A resident with respiratory failure, HTN, and anxiety became SOB and diaphoretic, received a breathing tx, and was sent by EMS to the hospital. The facility could not locate the required SNF/NF to Hospital Transfer form or other transfer records showing what information was communicated to the receiving provider.
Failure to Provide Transfer/Discharge Notices and Bed-Hold Documentation: The facility did not ensure that two residents received proper transfer/discharge notices and/or bed-hold offers after hospital transfers. One resident’s transfer/discharge notice was left blank for the resident or representative, and another resident’s record showed no documentation of a bed-hold offer and no resident/representative signature on the notice, despite the resident being able to make needs known and having multiple chronic conditions.
Failure to notify the Ombudsman of hospital transfers and an AMA discharge. Three residents with severe cognitive impairment were transferred to the hospital, but the EHR had no documentation that the Ombudsman was notified. A resident with moderate cognitive impairment was discharged AMA, and the resident was omitted from the Ombudsman discharge report because AMA residents were not included.
Failure to complete discharge and transfer documentation: A resident who left AMA had no documentation of provider notification, discharge summary, medication or oxygen arrangements, home health services, or PCP follow-up scheduling. In addition, multiple residents transferred to the hospital had no documented nurse-to-nurse report to the receiving facility, and some had no documented bed hold offer or written transfer notice. Staff interviews confirmed the missing documentation.
The facility failed to provide a written bed-hold notice for one resident and failed to send transfer/discharge notices to the LTC Ombudsman for two residents. One resident with MS and diabetes was hospitalized for a UTI, and another resident with respiratory and heart failure discharged home AMA; records did not show the required notices were completed.
Surveyors found that the facility failed to ensure effective discharge planning for two residents, including coordination with community agencies and medication management. The discharge policy lacked guidance on pre-discharge needs such as medication ordering, medication teaching, arranging home care services, equipment, and follow-up appointments. One resident with diabetes and dementia was discharged home with family caregivers but without documented medication teaching or scheduled follow-up, and the community case manager was not notified, preventing caregiver scheduling and leaving the family without insulin administration training. Another resident with cognitive impairment and prior documented safety concerns at home was discharged without in-home care ordered, medication refills sent, or a follow-up physician appointment arranged, and the resident later returned after not receiving care and running out of medications. The SSD reported not handling medication re-ordering or teaching and typically not making follow-up appointments, while leadership staff acknowledged they were unaware of the lack of discharge coordination.
The facility failed to notify the LTC Ombudsman of two resident discharges. One resident admitted with sepsis had intact cognition at discharge, and another admitted with influenza A had moderately impaired cognition at discharge; both were discharged home, but no Ombudsman notification was documented. The Admissions Manager stated notifications were only made for hospital transfers, while the Administer in Training stated every discharge should have been reported.
The facility failed to follow its bed-hold policy by not providing written bed-hold notices to two residents when they were transferred to the hospital, and by not maintaining signed copies in their medical records. One cognitively intact resident requested hospital transfer, and later hospital staff reported that when the resident was ready for discharge, the facility stated the prior semi-private bed was no longer available and only a four-bed room could be offered, which the resident declined, leading the hospital to find another facility. Another resident with mild cognitive impairment was transferred to the hospital by ambulance without any documented bed-hold notice. The DNS acknowledged that no bed-hold forms were signed or documented for these residents and that nursing staff were responsible for providing such notices when a return was expected.
Two residents with complex medical conditions, including kidney failure, pressure ulcers, infections requiring IV antibiotics, and isolation precautions, were transferred to the ED without the required clinical documentation and notices. Despite facility policies and a discharge checklist requiring a hospital transfer form, MAR, care plan, diagnostic results, advance directives, state transfer/discharge notice, and bed-hold information, an LPN sent only a face sheet and lab results and did not call the ED to provide a report. The ED reported receiving no paperwork for one resident and was unable to reach facility staff for a medication list or status report, and the state-required transfer/discharge and bed-hold notices were not provided to either resident or their representatives.
Surveyors found that the facility did not provide required written transfer/discharge notices and bed-hold information to several residents and/or their representatives when residents were sent to the hospital. Although facility policy required written notices specifying the reason, date, and destination of transfer along with appeal rights and Ombudsman contact information, review of electronic health records and transfer forms showed that these elements were missing, and no separate written notices were documented. Multiple transfer forms for residents sent to the hospital for issues such as abnormal labs, chest pain, uncontrolled pain, abnormal vital signs, suspected kidney infection, and unresponsiveness lacked any statement of appeal rights or Ombudsman contact details. In addition, bed-hold agreements were incomplete or absent, and there was no progress note documentation that bed-hold notices were provided, even though staff interviews confirmed that residents and representatives should have been notified and that such notification should have been documented.
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