Failure to Coordinate Discharge Planning, Community Services, and Medication Management
Summary
Surveyors identified a deficiency in the facility’s discharge planning process related to lack of coordination with community agencies and inadequate medication management for two residents. The facility’s Discharge Policy, revised 12/16/2026, did not address pre-discharge needs such as medication ordering, medication teaching, coordination of home care services, equipment needs, or ensuring follow-up appointments were made before discharge. For Resident 1, who had diabetes and dementia but was assessed as cognitively intact, the Discharge Plan of Care documented that assistance with bathing, toileting, and dressing would be provided by family and personal caregivers, but there was no documentation of medication teaching or follow-up appointments. The Home and Community Services case manager reported they were not notified of this resident’s discharge, so caregivers could not be scheduled, and the family later called with questions about sliding scale insulin administration because they had not received training from facility nurses before discharge. For Resident 2, who had unspecified cognitive impairment, adult failure to thrive, and needed assistance with personal care, the admission documentation included prior hospital case management concerns about safety at home and the family’s ability to provide care. The Discharge Plan of Care stated the resident was cognitively intact and would receive assistance with most ADLs from family, but in-home care was not ordered, medication refills were not sent to a pharmacy, and no follow-up appointment with the primary physician was made. The resident was later readmitted after not receiving care at home and running out of medications about a week after discharge. The Home and Community Services case manager stated they had not been notified of this resident’s discharge and indicated that, based on identified concerns, involvement would have been expected upon referral. The Social Services Director acknowledged not knowing about medication re-ordering or teaching for discharges and reported typically not making follow-up appointments, while leadership staff acknowledged lack of awareness of the coordination issues and that the discharges for these residents were not safe.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Notify Ombudsman of Hospitalizations, Discharges, and Transfers: Social services did not send the required monthly notices to the LTC Ombudsman regarding resident hospitalizations, discharges, and transfers. The ombudsman reported receiving no notices for 2025 or 2026, and the administrator confirmed the notices had not been sent for over a year. The facility policy reviewed did not address the process for ombudsman notification.
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.
Two residents who experienced emergent hospital transfers for issues including abnormal critical labs, uncontrollable pain, and SOB with low O2 saturation were not provided with required written bed-hold policies and transfer notices. One resident had severely impaired cognition, and another was cognitively intact and later died at the hospital. Progress notes documented the transfers and that contacts or family were notified, but there was no documentation that written notices addressing bed-hold, appeal rights, or ombudsman information were given, despite facility policies requiring such written information at admission and again at or shortly after transfer. The Administrator confirmed that bed-hold notices were not sent for these residents.
Failure to Notify State LTC Ombudsman of Resident Discharge: The facility failed to send the required discharge notice to the State LTC Ombudsman for a resident who was discharged. The Ombudsman stated she never received the notification, the SW had no evidence of a report and was unaware of the monthly notification requirement, and the Administrator stated she did not know the rule. The resident had ischemic cardiomyopathy and a blank BIMS score.
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.
The facility failed to provide written transfer/discharge notices for three residents who were sent to the hospital, and for one resident it also failed to provide written bed-hold policy information. In one case, an LPN said she did not notify the guardian because she was the only nurse on the unit and did not have time, and there was no evidence that the Ombudsman was notified of the transfers.
Failure to Notify Ombudsman of Hospitalizations, Discharges, and Transfers
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman of resident hospitalizations, discharges, and transfers for calendar years 2025 and 2026. During interview, the ombudsman stated she had not received any hospitalization, discharge, or transfer notices for 2025 and none for 2026. Social services staff stated they were responsible for sending these notifications monthly and confirmed they were behind in submitting them. The administrator stated social services was responsible for the monthly notices, confirmed the notices had not been sent for over a year, and stated the ombudsman is a resource for residents if they feel they have been wrongly hospitalized, discharged, or transferred. A facility policy titled Discharge Planning dated 12/25 was reviewed and did not address the process for sending ombudsman notifications.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify the resident or the resident’s representative of its bed-hold policy for two hospital transfers. Facility policy stated that at the time of transfer for hospitalization or therapeutic leave, the facility would provide written notice explaining the duration of the bed-hold policy and information about the resident’s return to the next available bed, and that in an emergency transfer the notice would be provided within 24 hours. For Resident R24, who had diagnoses including high blood pressure, kidney disease, and hypokalemia, the record showed a hospital transfer on 3/31/26 and return on 4/5/26, but there was no documented evidence that written bed-hold information was provided at the time of transfer. For Closed Resident Record CR87, the record showed diagnoses including hyperlipidemia, congestive heart failure, and a right femur fracture. On 2/6/26, staff received venous doppler results indicating a nonocclusive thrombus in the right common femoral vein, relayed the results to the CRNP, and obtained orders to increase Eliquis temporarily and repeat an ultrasound. After the resident’s daughter called and staff reported the situation to the CRNP, the resident was sent to the hospital around 5:50 p.m. The emergency room transfer form and the clinical record did not include documented evidence that CR87 or the representative were provided written information about the facility’s bed-hold policy at the time of transfer.
Failure to Provide Required Bed-Hold and Transfer Notices for Hospital Transfers
Penalty
Summary
The deficiency involves the facility’s failure to provide required written bed-hold policies and transfer notices to two residents and/or their resident representatives when the residents were emergently transferred to the hospital. One resident had severely impaired cognition with a BIMS score of 3/15 and was transferred to the hospital due to abnormal critical lab results, then later returned to the facility. Documentation showed that the facility called the contact on file and a POA returned the call, but there was no documentation that a written transfer notice or bed-hold information was provided. The facility’s own policy required that written transfer/discharge notices include the reason for transfer, effective date, receiving location, a statement of the right to appeal, and contact information for the state LTC ombudsman and protection and advocacy agencies, as well as sending a copy to the ombudsman. A second resident, who had intact cognition with a BIMS score of 15/15, was transferred to the hospital on one occasion for uncontrollable pain and returned to the facility, and on another occasion for SOB, tremors in both arms, and oxygen saturation below 88%, after which the resident expired at the hospital. Progress notes documented the transfers and that the family was notified, but there was no documentation that written transfer notices or bed-hold policies were provided at either transfer. The facility’s bed-hold policy required that all residents or their representatives, regardless of payor source, receive written information about facility and state bed-hold policies twice: in advance of transfer (e.g., in the admission packet) and again at the time of transfer, or within 24 hours for emergency transfers. During an interview, the Administrator confirmed that bed-hold notices had not been sent for these two residents.
Failure to Notify State LTC Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to send a copy of Resident #8’s discharge notice to the representative of the Office of the State Long-Term Care Ombudsman before the resident was discharged. Resident #8’s nursing home discharge MDS assessment dated 04/13/2026 identified him as a [AGE]-year-old male admitted to the facility on [DATE], with an active diagnosis of ischemic cardiomyopathy and a blank BIMS score. During interview, the Ombudsman stated she had never received a discharge notification from the facility and said the facility was required to submit discharge notification every time it did an involuntary discharge, transfer, or presented discharge paperwork to a resident related to discharge. The Social Worker stated she had no evidence of a report to the state Ombudsman for Resident #8’s discharge and was not aware she was supposed to send discharge notification monthly. The Administrator stated she was unaware of the rule to notify the state Ombudsman of any resident discharges. Record review of the facility’s Transfer and discharge policy stated that a copy of the notice shall be provided to the representative of the Office of the State Long-Term Care Ombudsman and that the Social Services Director, or designee, shall provide notice of transfer via monthly list.
Missing Hospital Transfer Documentation
Penalty
Summary
The facility failed to ensure hospital transfer documentation was completed for one resident who was transferred to the hospital after complaining of not being able to breathe and appearing diaphoretic. The resident had diagnoses of respiratory failure, high blood pressure, and anxiety disorder, and was able to make needs known. A breathing treatment was provided, and the provider agreed to send the resident out for further evaluation, after which emergency transportation took the resident to the hospital. Record review found no documentation showing what information was provided or communicated to the receiving facility for the transfer. Staff stated that transfer documentation should have included a SNF/NF to Hospital Transfer form, the resident's face sheet, and the medication and treatment administration records, but they were unable to locate documentation showing these items were completed or sent for the resident's hospital transfer.
Failure to Provide Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The facility failed to provide a written notice of transfer/discharge before facility-initiated hospital transfers for 3 of 6 sampled residents (#6, #69, and #77). Medical record review showed resident #6 was transferred to the hospital and there was no evidence that a written transfer/discharge notice was issued to the resident or resident representative. There was also no evidence that a representative of the Office of the State Long-Term Care Ombudsman was notified of the transfer. The Regional Clinical Director confirmed there was no evidence the notice had been provided. Resident #69 was transferred to the hospital and the record showed no evidence that the facility issued a written transfer/discharge notice to the resident or the resident's guardian. An LPN stated she did not notify the guardian because she was the only nurse on the unit and did not have time, and she reported to the next shift that the guardian had not been notified. The guardian confirmed she had not been notified of the transfer. Resident #77 was transferred to the hospital and the record showed no evidence that the facility issued a written transfer/discharge notice or written information on the bed-hold policy to the resident or resident representative, and there was no evidence that the Ombudsman was notified of the transfer. The Regional Clinical Director confirmed there was no evidence the bed-hold and transfer/discharge notices were provided.
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