A resident was discharged to a motel with home health services, a wheelchair, medications, and a follow‑up medical appointment arranged, and received education on medications, blood glucose monitoring, emergency response, and home health services. Discharge planning discussions and a referral to the Take Me Home program were documented, and the facility agreed to pay for an initial period of the motel stay. However, record review and staff interviews confirmed that the resident was not given the required 30‑day written discharge notice prior to leaving, limiting the resident’s ability to prepare for discharge and exercise discharge‑related rights.
Failure to Notify Ombudsman of Resident Transfer: A resident was transferred to the hospital, but the facility did not send the Notice of Transfer/Discharge form to the LTC Ombudsman and had no record that the Ombudsman was notified of the hospitalization. The SW confirmed the paperwork had been overlooked before surveyor intervention.
Surveyors found that discharged residents were not given written information about their right to appeal discharge or how to contact the Ombudsman or State Agency. Review of discharge paperwork for three discharged residents showed no documentation of appeal rights or related contact information. The DON confirmed that this information was not included in the discharge documents, and the Administrator acknowledged the issue during the survey exit.
A resident was denied readmission following hospitalization without receiving the required written discharge notice, which should have included the reason for discharge, effective date, and appeal rights. The resident, their representative, and the LTC ombudsman were not notified, and there was no evidence of coordinated discharge planning with the hospital or community services. The Administrator and DON confirmed that the necessary notice was not issued.
A resident was transferred to a hospital and, after remaining hospitalized beyond the bed-hold period, was denied readmission by the facility despite hospital documentation showing readiness for return. The facility did not provide the required written discharge notice to the resident, their representative, or the LTC ombudsman, nor did it coordinate discharge planning with the hospital or community services. This resulted in an involuntary discharge without proper notification or appeal rights.
A resident was transferred to a hospital following a fall, altered mental status, and high blood glucose, but the facility did not document which required transfer documents were sent with the resident. Although a transfer checklist was signed by a nurse and ambulance staff, none of the items were checked to indicate what information was provided to the hospital.
The facility failed to provide timely and proper notification to the State Long Term Care Ombudsman and, in some cases, to residents or their representatives regarding transfers and discharges. In multiple instances, required notices were either not delivered, not documented, or only sent after surveyor intervention, including a case involving a resident who was discharged following threats and illegal drug use. This deficiency was found in all reviewed cases of transfer and hospitalization.
The facility did not provide required discharge documentation and notifications for two residents who were hospitalized, including missing Bed Hold Notices and lack of ombudsman notification. The DON and NHA confirmed that the necessary forms could not be located.
A resident left the facility for a procedure and did not return, but the required transfer or discharge notice was not completed. The DON and Administrator confirmed that no documentation was provided, as staff did not think it was needed in this case.
The facility did not provide written notification of hospital transfers or the bed hold policy to the MPOA for three residents, and also failed to notify the ombudsman for two of these residents. These omissions were confirmed by record review and the DON.
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