Failure to Provide Required Transfer and Bed-Hold Notices: Two residents were transferred to the hospital, but the record did not show that care plan goals or current orders were sent with them. The chart also lacked documentation that bed hold or transfer notice information was provided to the resident or representative at the time of transfer, and the transfer notices reviewed did not include required appeal rights details or Ombudsman contact information.
The facility failed to submit monthly transfer and discharge notices to the Ombudsman. During survey, the Administrator confirmed that the required notices had not been sent and stated they had not been submitted since she began working at the facility in September 2025.
The facility failed to provide and document written bed hold policy notification when two residents were transferred to the hospital. One resident, who received dialysis and was sent out for bleeding from an AV fistula after treatment, had no record of notification to the resident or RP. Another resident was transferred after low BP during an avascular appointment, and staff could not produce written proof that the RP received the bed hold policy.
Failure to Document Hospital Transfer Notices and Bed-Hold Information: The facility did not ensure that written notice of hospital transfer and bed-hold policy information were documented for two residents who were transferred to the hospital. One resident had anemia and altered mental status, and another had acute respiratory failure with hypoxia and repeated hospitalizations for pneumonia and hypoxia. The DON stated that family notification and bed-hold completion were part of the process, but no documentation was available for either resident.
Failure to Provide Written Transfer/Discharge and Bed-Hold Notifications: The DON and record reviews showed that written transfer/discharge notices, bed-hold information, and Ombudsman notifications were not properly documented for multiple residents. In some cases, forms were incomplete or unsigned, and in others the facility could not verify that the resident, RP, or Ombudsman received the required written notice. One resident with cognitive impairment had incomplete transfer and bed-hold forms, while another cognitively intact resident stated no form was offered or received.
A complaint investigation found that the facility failed to provide a receiving facility with a comprehensive discharge summary and complete medications for a resident being discharged. The discharging LPN reported not being familiar with the discharge process, did not send narcotic medications, and only sent non-narcotic medications. Documentation showed that a neurology team from the receiving facility later picked up some narcotics and signed for them. The DON stated that narcotics are only sent with a physician’s order and produced printed prescriptions, but record review did not show any physician order to send narcotics with the resident or any documented discharge note summarizing the resident’s stay and courses of treatment and care.
A resident identified for transfer due to a bed lock was referred by the Social Service Director to two other SNFs without prior discussion of the proposed transfer with the resident’s known medical decision maker. The Business Office Manager stated the resident was chosen because they were easygoing and reported that referrals were made in the context of opening rehab beds, while assuming Social Services had notified the representative. The resident’s representative only learned of the transfer when contacted by an outside facility, and later reported confusion and upset that another family member was called instead. The DON stated that the expectation is to discuss proposed transfers with residents or their representatives before sending referrals, and the Ombudsman reported not being notified of the bed lock or the residents referred out.
The facility failed to provide a written bed-hold notification to a resident or representative at the time of a hospital transfer following a fall, despite having a policy requiring that a bed-hold form be given whenever a resident is transferred out. In addition, the facility did not notify the local ombudsman in a timely manner about the discharges of two residents—one who was sent to the hospital and did not return and another who expired in the facility—with notifications instead occurring later by e-mail.
The facility failed to provide required written bed hold and transfer notices when residents were sent to the hospital. For three residents reviewed, records and staff interviews showed the notices were either not sent or could not be documented as sent to the resident or responsible representative, including missing email support and no copy in the chart.
A resident was discharged to home, but the facility could not provide written evidence that the State Ombudsman’s Office was notified of the discharge. The DON said the SW was responsible for ombudsman notification by email, while the SW designee could not verify that the prior SW had sent the notice and was unable to confirm it by phone.
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