Two residents who were transferred to a hospital did not receive required written bed-hold notifications. One resident was involuntarily transferred after aggressive behavior toward a peer, and the RN who arranged the transfer did not provide the bed-hold notice due to attending multiple emergencies. Another resident, who called 911 after feeling unwell, was only verbally informed by the DON that a return to the facility was possible, with no written bed-hold policy documented in the record. These actions did not follow the facility’s guideline requiring written presentation of the state and facility bed-hold policy at or shortly after transfer, with documented attempts if direct provision is not possible.
A resident with new-onset cardiomyopathy requiring a LifeVest cardiac monitor was readmitted and later discharged without physician orders or care plan focus for device management, and without documented discharge teaching on cardiac monitoring, device care, complications, or cardiology follow-up. Nursing staff acknowledged forgetting to enter cardiac monitoring orders, assuming other staff changed the battery and that the resident knew how to manage the device. The discharge form only noted that the resident left with the cardiac vest, while facility policies and its cardiopulmonary program description required documented education, equipment management instructions, and discharge teaching for such devices.
Failure to provide written transfer information to the hospital for a resident sent to the ER with leaning, drooling, and slurred speech. The resident had COPD, PNA, and sepsis, but the chart lacked a full assessment, VS, blood sugar, and pulse ox documentation, and the RN confirmed no written transfer form was sent with the resident’s assessment findings, meds, family contact info, or AD status.
A cognitively intact resident who was independent in self-care and mobility received an involuntary discharge notice for non-payment, while the ombudsman was actively assisting with an appeal and hearing. The resident chose to leave and was discharged home before the planned discharge date, but the facility did not notify the ombudsman of this discharge. The ombudsman learned of the discharge from an APS worker and confirmed that no discharge notice had been received, and the administrator acknowledged that required notification to the ombudsman, as outlined in facility policy, had not been provided.
A resident with multiple psychiatric and substance use diagnoses received an emergency involuntary discharge notice that lacked required information about appeal rights and advocacy agencies. The notice did not include the mailing and email address of the entity to receive an appeal, nor instructions on obtaining, completing, and submitting an appeal form. It also omitted the name, mailing address, email address, and phone number of the State LTC Ombudsman and the agency responsible for protection and advocacy of individuals with mental illness. The Administrator and DON later confirmed that these required elements were missing and that the Administrator was unaware of all requirements for an involuntary discharge notice.
Failure to notify the physician and provide medications when a resident left AMA. A cognitively intact resident with DM2, bipolar disorder, HTN, asthma, and wound care needs left after being educated on the risks and benefits of continued treatment, but the record did not document physician or NP notification. The assigned nurse said she did not notify the physician or give any meds, and social service staff said nurses were responsible for notifying the physician and providing 2 weeks of medications.
A resident was returned to the hospital after the facility received a criminal background report indicating the resident was a registered sexual offender, but the facility did not complete or document the required transfer/discharge process. The facility’s policy required appropriate discharge procedures and a written or telephone physician order for transfer or discharge, yet the resident was dropped off at the ED with a stated social concern and later sent back again for nursing home placement without any discharge notice or discharge orders in the medical record. The resident’s POA was informed that the transfer was due to the background check results, and the SSD confirmed the CHIRP findings, while the Administrator verified that no required discharge documentation existed in the chart.
A bariatric resident with diabetes and bipolar disorder, weighing 426 lbs and requiring specialized equipment, was discharged to another nursing home without proper verification, documentation, or discharge instructions. Social services did not clearly document or confirm the receiving facility, and the administrator of the intended facility reported the resident was never admitted there. Upon arrival, the intended facility lacked a bariatric bed and wheelchair, leading to the resident being sent to the ER, where a different nursing home was found. The discharging LPN provided only medications without written discharge papers, contrary to the DON’s expectations and facility policy requiring documented communication of necessary information and DME needs to the receiving institution.
A resident with end stage renal disease and dependence on renal dialysis was discharged home with the wrong medications after an LPN completed discharge teaching and sent the family home with medications that did not belong to the resident. Later, the LPN realized the resident’s medications were still at the facility and contacted the family, who reported they had received medications that were not theirs and returned them. The DON stated that a two-nurse verification system is expected for discharge medications. Records showed discharge orders, a medication list, a care plan for medication administration, discharge teaching documentation, and an incident report for the wrong medications, along with a policy requiring review of discharge instructions and medication lists and provision of appropriate medications per MD orders at discharge.
A resident with a history of CVA, hemiplegia, aphasia, depression, pain, and unsteadiness, who used a manual w/c for mobility, experienced prolonged delays in transfer to a supportive living facility because the facility repeatedly failed to provide complete and accurate discharge documentation, including SS information, Medicare/Medicaid status, and resident funds records. Physician orders specified that the resident required a properly sized w/c with defined features for mobility, but there was no record that a new w/c was ordered, and the resident was discharged with her own older w/c, which was later observed to be in serious disrepair with cracked and broken side panels, missing plastic, and worn, flat cushioning. The resident and supportive living staff reported that she had requested a new w/c for months, that the facility gave inconsistent information about ordering it, and that the lack of proper documentation and failure to purchase the w/c delayed her admission and left her using the damaged device.
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