The facility failed to complete discharge summaries for two residents who were discharged from the LTC facility. One resident was transferred to the hospital after reporting intolerable abdominal pain and did not return, and another resident was discharged home with home care services. The DON confirmed that no discharge summaries were completed for either resident.
The facility failed to provide written transfer notices and bed hold policy information to residents and their representatives for multiple hospital transfers, and an LPN/social services designee confirmed the notices had not been given and the Ombudsman had not been notified. Residents involved had diagnoses including pneumonia, COPD, and rhabdomyolysis, and one resident was transferred for shortness of breath. The facility also lacked a proper discharge summary with a recapitulation of stay for a resident who died and was discharged to a mortuary.
The facility failed to ensure the Ombudsman was informed of all resident discharges and transfers. Record review showed that two residents had an emergency hospital transfer or discharge, but neither resident was included on the monthly transfer forms sent to the Ombudsman. The SSD confirmed the events were not reported as required.
A resident with a displaced R tibia fracture, fracture with routine healing, and HTN was transferred to the hospital for low BP, but the facility had no evidence that the resident or resident representative was given written notice of the reason for the transfer in a manner they could understand. The DON confirmed the lack of written notification at the time of transfer.
Missing discharge summaries and transfer notifications: The facility failed to complete required discharge documentation for two residents who were transferred out of the facility. One resident was sent from an appointment to the hospital for kidney failure and had no documented transfer notice or discharge summary, including required medical and contact information, and the DON confirmed the resident’s representative was not notified in writing. Another resident was discharged without a facility Discharge Summary, which the DON confirmed.
A resident was transferred to the hospital on multiple occasions, but the facility did not provide the required written bed-hold information or written reasons for transfer at the time of each hospitalization. Facility policy requires that residents and their representatives receive written information on State bed-hold duration and payment amounts before hospital transfer or therapeutic leave, and that this information be provided at admission and prior to each transfer. Record review showed no bed-hold notices or transfer-reason documentation for any of the resident’s hospital leaves, and the Social Service Director confirmed that no such forms were completed, despite the policy and staff education requirements.
The facility did not send federally required transfer documentation to the receiving health care institution for two residents who were transferred to the hospital after falls. Review of records and interviews with the Administrator confirmed that essential information, such as practitioner contacts, resident status, and care plans, was not provided at the time of transfer.
A resident was discharged without the required notification to the state LTC Ombudsman. Review of records and interviews with the Social Services Director revealed that the facility's process only included ombudsman notification for hospital transfers, not discharges, resulting in the omission of the discharge notice for this resident.
A resident was discharged from the facility, but staff did not notify the state ombudsman as required. Review of records and staff interviews confirmed that notifications of emergency transfers and discharges were not consistently sent each month, resulting in the omission of the required discharge notification for this resident.
Two residents with complex medical conditions were transferred to the hospital without receiving written notice of transfer, including the reason for transfer, as required. In both cases, the Bed Hold/Therapeutic Leave Forms were incomplete, and the Director of Nursing confirmed that neither the residents nor their representatives were provided with the necessary written documentation.
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