Failure to notify the State LTC Ombudsman office of a resident’s discharge. A resident admitted with respiratory failure was discharged, but the clinical record did not show Ombudsman notification, and the discharge list sent to the Ombudsman did not include the resident. The BOM verified the resident was omitted from the list, and the Administrator stated that a complete list of discharged residents was to be sent.
A resident with a stroke history and moderate cognitive impairment was hospitalized, but the record did not show that the resident or family received bed hold information. The family said no bed hold notice was provided, while staff reported that the policy was sent in a transfer packet and that follow-up to confirm receipt was not consistently done; the DON and admissions director gave differing accounts, and the administrator said bed hold information was mainly directed toward skilled residents.
A resident with CHF and epididymitis was transferred to the hospital for scrotal swelling, but the clinical record did not show that a written bed hold notice was given to the resident or representative. The DNS stated the charge nurse was responsible for providing the bed hold policy at transfer, and the Administrator confirmed the form was not completed.
A facility failed to notify the State LTC Ombudsman Office of resident discharges as required by policy. The Business Office Manager stated the discharge list had not been sent for several months, and the Administrator acknowledged the monthly update was missed due to business office staffing changes.
The facility failed to provide written transfer notices and written bed-hold policy information to three residents or their representatives at the time of hospital transfer. One resident with UTIs and sepsis and another with chronic heart failure, both responsible for their own decisions, were transferred without documented written notice or bed-hold information. A third resident with peripheral vascular disease, whose daughter was the responsible party, was transferred twice without documentation that the representative was notified. An LPN reported not documenting which documents were sent and that no written transfer notices were available, another LPN was unaware of the requirement to provide bed-hold or transfer notices, and the DNS could not find any related documentation and was unaware written transfer notices were required, while the administrator acknowledged such notices and bed-hold information were supposed to be provided.
Three residents discharged from the facility did not have complete discharge summaries. The documentation for each lacked essential information such as home instructions, recapitulation of the stay, and, in one case, the name of the home health provider. The DNS confirmed these assessments were not thoroughly completed.
The facility did not notify the state Long Term Care Ombudsman’s office when two residents—one with post-surgical cellulitis and another with Alzheimer’s and metabolic encephalopathy—were transferred to the hospital and subsequently discharged. Record reviews and staff interviews confirmed that required notifications were not made, and key staff were unaware of this requirement.
The facility did not provide required written bed-hold notifications to residents or their representatives and failed to notify the LTC Ombudsman during transfers to hospitals and discharges home. This deficiency was confirmed for four residents with conditions such as heart failure, kidney disease, stroke, and alcohol abuse, with staff interviews and record reviews showing that these notifications were not completed as required.
The facility did not notify the state LTC Ombudsman of discharges for three residents, including individuals with diabetes, stroke, and heart failure, as required. Documentation and discharge forms did not include these residents, and staff confirmed the lack of notification.
Two residents who were transferred to the hospital did not receive required written notification of the Bed Hold Policy or transfer notice, despite being cognitively intact. Staff and leadership confirmed that the necessary documentation and notifications were not provided at the time of transfer, and the events were not properly recorded in the clinical records.
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