Failure to notify the Ombudsman of a resident discharge. A resident with metabolic encephalopathy, DM2, and HTN was admitted for therapy, then the family raised concerns about room space and chose to take the resident home AMA. Record review and staff interview showed the discharge notice was not sent to the Ombudsman, despite the regulatory requirement to do so.
The facility failed to provide required transfer/discharge notices to residents and to send copies of those notices to the State Long-Term Care Ombudsman. Several residents with conditions such as hemiplegia after stroke, COPD, atherosclerotic heart disease, hepatic encephalopathy, and cirrhosis were discharged to home, hospice, another SNF, or an acute hospital without documentation that the ombudsman received a copy of the discharge/transfer notification. In multiple cases, discharge summaries and forms documented the discharge destination, services, and follow-up appointments, but did not include ombudsman contact information or appeal rights, and there were no physician discharge orders for some residents. Staff, including the Resident Relations Manager, Business Office Manager, and ED, reported that the NOMNC was the only form used as a discharge/transfer notice, acknowledged that it lacked ombudsman and advocacy contact information, and confirmed that they did not send copies of discharge/transfer notifications to the ombudsman, instead emailing only a monthly list of discharged or transferred residents.
A resident with paraplegia, depression, and generalized weakness, who was cognitively intact, requested transfer to another SNF after a staff member told her she was in the wrong (short-term) facility and should look into another placement for long-term care. Social services initiated an SNF-to-SNF referral and discussed transfer procedures with an individual initially treated as a family/POA, later clarified to be a non-family contact authorized by the resident. The facility issued same-day written transfer/discharge notice citing improved health and no longer needing services, and nursing documented the resident’s departure and notification of a POA/family member, but there was no documentation that the OSLTCO was notified at the same time as the resident, nor evidence of discharge planning in the care plan. The resident reported she only signed with an initial, did not understand her appeal rights or the option to consult an ombudsman, and the OSLTCO and facility leadership confirmed that the facility only provided monthly notifications and lacked a specific policy for ombudsman notification for non-emergency transfers.
A resident with multiple medical conditions, who was cognitively intact and receiving PT, OT, and speech therapy, was discharged to a group home after the facility documented that the resident’s health had improved and services were no longer needed. The facility issued a Notice of Proposed Transfer/Discharge on the day of discharge that incorrectly listed the State Agency as the appeals authority and did not send a copy of this notice to the ombudsman. The ombudsman reported only receiving monthly discharge lists and no discharge notices, while the case manager, SS Director, and DON confirmed that copies of proposed transfer/discharge notices were not routinely sent to the ombudsman and that their discharge policy did not specify required notification content for residents, representatives, or the ombudsman.
A resident with multiple orthopedic and neurologic conditions was transferred to another facility after a referral, insurance authorization, and acceptance were documented, and a discharge MDS indicated the resident’s return was not anticipated and that she was cognitively independent. Although staff described a process in which nursing and social services complete discharge summaries with information on home health, DME, follow-up providers, and contact information, they reported that they do not complete discharge summaries or document them in the chart when a resident transfers to another facility, instead sending clinical information and orders as a transfer packet. The MDS coordinator confirmed that this situation met the definition of a discharge and that no discharge summary was present in the record, and leadership acknowledged there was no facility policy specifically addressing discharge summaries.
Two residents were transferred to the hospital for acute changes in condition, including unresponsiveness and hypotension, with documentation in nursing notes, physician visit notes, transfer forms, and discharge MDS assessments indicating hospital transfers with return anticipated, but no written transfer/discharge notices containing required elements were found in their records. One resident had multiple serious conditions including acute respiratory failure, heart failure, and pneumonia; the other had ventilator-associated pneumonia, sepsis, respiratory failure with hypercapnia, and severe cognitive impairment. Staff interviews revealed that Social Services was not involved in notifications, the Medical Records Director only began tracking notifications months after the events and was unsure how mailed notices were tracked, and the liaison who visited residents in the hospital did not provide any transfer/discharge forms. The Medical Records Director confirmed no transfer/discharge notices existed for the two residents and that the form in use contained incorrect appeal and ombudsman contact information, while the Administrator stated she was unaware that this version of the form was being used. Review of the facility’s discharge/transfer policy showed it addressed bed-hold review after emergent transfers but did not address providing written transfer/discharge notices or the required content.
The facility failed to provide required written transfer/discharge notices and to notify the State LTC Ombudsman for three residents who were either transferred to the hospital or discharged home. One resident with multiple comorbidities, including dementia and failure to thrive, was sent to the ED at a family member’s request, but there was no documentation of Ombudsman notification. Two cognitively intact residents with complex medical histories had planned discharges home with complete discharge paperwork, including medication lists and personal effects inventories, yet no Ombudsman notification was documented. The Ombudsman office reported not receiving discharge notices for an extended period, the Social Services Manager admitted she had not been formally notifying the Ombudsman, and the DON acknowledged the facility was unaware that notification must be in writing; the written discharge/transfer policy did not address resident notice content or Ombudsman notification.
Two residents were discharged home after skilled stays, one with metabolic encephalopathy, COPD, and anxiety and the other with speech language deficits and type II diabetes, with documentation showing IDT discharge planning, physician orders for discharge, discharge summaries, and progress notes confirming stable discharge with medications and family support. Despite this, there was no evidence that the Ombudsman was notified or provided copies of the discharge notices for either resident, and the DON reported that while residents and representatives are typically given written discharge information and Ombudsman contact details, the facility’s transfer/discharge policy did not include a requirement to notify the Ombudsman.
A resident with dementia and on anticoagulant therapy was transferred to the hospital after a family member noticed a bruise and called 911. Only a face sheet was provided during the transfer, and the required documentation, including relevant diagnoses and medical information, was not sent with the resident. Staff interviews revealed a lack of awareness about required transfer documents, and the facility's policy for emergency transfers was not followed.
A resident with a lower right femur fracture and intact cognition was discharged AMA after signing an AMA form and understanding the risks. The facility did not include this discharge in its monthly notification to the State LTC Ombudsman, despite policy and staff expectations that all discharges, including AMA, be reported.
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