The facility failed to give written transfer notices to residents and/or their representatives when two residents were sent to the hospital, including the reason for transfer and bed-hold information. One resident was transferred for evaluation and treatment of worsening wounds, and the representative said no bed-hold paperwork was provided. The facility also did not send the hospital transfer notices to the local Ombudsman for the two residents, and staff interviews showed confusion about who was responsible for reporting hospitalized residents.
A resident was transferred to a hospital and did not return, yet the facility failed to provide or document the required written transfer and bed-hold notices. Staff reported that residents transferring out are supposed to sign transfer and bed-hold forms, with nurses completing and assisting with signatures as needed, but could not confirm that this occurred for the resident involved. Review of facility policies showed that written notices explaining the reason, effective date, and destination of a transfer, as well as bed-hold notices given in advance and at the time of transfer or within 24 hours for emergencies, must be provided and kept in the clinical record; however, no such notices were found for this resident, and a facility document indicated there was no bed hold for the transfer.
A quadriplegic resident was transferred to another facility without being provided with a wheelchair, despite reliance on it for mobility, and arrived at the receiving facility without one. Additionally, the facility did not document the discharge in the medical record, omitting key information about the transfer and the resident's care.
The facility did not consistently provide required written notifications of resident transfers and discharges to the local Ombudsman, as mandated by policy. Several residents were transferred to hospitals or discharged, but the responsible staff member failed to send or retain copies of the notifications, and the Ombudsman reported not receiving them for an extended period.
The facility did not provide timely notification to the State Long-Term Care Ombudsman regarding the transfer and discharge of three residents. Interviews and record reviews showed that required notifications were not sent, and staff responsible for this process was unaware of the requirement, resulting in missing documentation in the affected residents' charts.
A resident was transferred to the hospital on two occasions without receiving the required written notice explaining the reason for transfer. Staff confirmed that the transfer notices were not completed, and no documentation was found in the medical record or provided upon request, despite facility policy requiring such notification.
A resident and their representative were not given written notification of the facility's bed hold policy when the resident was transferred to the hospital, as confirmed by staff and a review of facility policy.
A resident who was transferred to the hospital did not receive the required transfer discharge notice or bedhold documentation. Staff confirmed the absence of these documents and acknowledged ongoing problems with providing them, and record review showed no evidence of the required forms in the resident's file.
The facility did not notify the State Ombudsman Office or provide required ombudsman contact information to residents during hospital transfers or discharges. Staff interviews revealed a lack of awareness about these requirements, and review of transfer/bed hold notices for several residents confirmed the omission. The facility was unable to provide documentation of ombudsman notification for these events.
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