Failure to Notify State LTC Ombudsman of Resident Discharge: The facility failed to send the required discharge notice to the State LTC Ombudsman for a resident who was discharged. The Ombudsman stated she never received the notification, the SW had no evidence of a report and was unaware of the monthly notification requirement, and the Administrator stated she did not know the rule. The resident had ischemic cardiomyopathy and a blank BIMS score.
Surveyors found that the facility failed to provide required written transfer/discharge notices, including appeal rights and Ombudsman notification, for three residents with dementia and elopement or wandering concerns. One resident with moderate cognitive impairment was moved to another city’s secure unit while a family member was out of the country, after only a handwritten notice was given the day before transfer and after the Ombudsman had advised the facility to provide proper notice. Another resident with vascular dementia was labeled as having eloped after going outside to see fireworks, then was discharged to another town without any 30‑day or prior written notice. A third resident with severe cognitive impairment and documented elopement risk was transferred to a secure unit at another facility based only on verbal agreement with the responsible party, with no written notice in the record. The ADM acknowledged that written notices were not provided because families were involved in discussions, and the SW reported uncertainty about the discharge process, despite a facility policy requiring 30‑day written notice (or as soon as practicable in exceptions) with specific content and evidence of notice to the LTC Ombudsman.
A resident with COPD, ADHD, insomnia, Type 2 diabetes, and bipolar disorder, who was cognitively intact, received two involuntary discharge notices, but the facility did not send copies of these notices to the State LTC Ombudsman as required by its own transfer/discharge policy. Record review showed no documentation that the Ombudsman was notified, and the Ombudsman confirmed she had not received notice of either discharge. The Social Worker reported she was unaware of a requirement to notify the Ombudsman, while the Regional President of Operations stated the Ombudsman should receive a copy of discharge notices. The Business Office Manager acknowledged that notifying the Ombudsman was her responsibility and that she failed to do so when both discharge notices were issued.
Incomplete Transfer and Discharge Notice: A resident with severe cognitive impairment, fractures, pain, and discharge-planning difficulties received a discharge notice for nonpayment that listed an out-of-state address but did not identify a confirmed safe discharge location. The notice also omitted the Ombudsman's name and email address, and staff interviews showed the facility had not verified the discharge destination or provided the notice to the Ombudsman's office.
A resident admitted with cellulitis, HTN, wound infection, and risk of malnutrition, and assessed with moderate cognitive impairment and need for supervision with most ADLs, chose to leave AMA to a community shelter after refusing care, medications, and wound treatment. The SW documented informing the resident that leaving would be AMA and that medications could not be sent, and nursing documented that leadership was aware and the resident left with belongings. However, the physician discharge summary left the condition upon discharge, prognosis, and discharge diagnosis sections blank and did not include special instructions, precautions, or risks related to the AMA discharge. The EHR contained no completed AMA form signed by the resident or staff, and interviews confirmed that required AMA procedures and written discharge instructions outlined in facility policy, including execution of AMA forms, were not documented for this discharge.
A resident with dementia, cancer, anxiety disorder, and psychosis, who had impaired cognition and a legal guardian, was transferred to another nursing facility after two resident-to-resident altercations. The care plan required contacting the guardian for all changes, and the EMR documented the transfer, but there was no written transfer or discharge notice to the resident, the guardian, or the State LTC Ombudsman. The guardian reported receiving only a phone call explaining the move and was not given written notice or options for the receiving facility, and the Administrator confirmed that no written notice was completed despite facility policy requiring such notice when safety is endangered.
The facility failed to notify the LTC Ombudsman of two resident discharges. One resident with UTI, weakness, cirrhosis, DM2, obesity, HTN, and sepsis was sent to the hospital, and another resident with CHF, PVD, and a pacemaker was discharged home; both had discharge plans and records showing no ombudsman notice. The SSD and ADM stated they were unaware the ombudsman had not been receiving discharge notifications, and the ombudsman reported no notices from the facility since 10/3/25.
Failure to Notify LTC Ombudsman of Resident Discharges: The facility failed to send discharge notices to the LTC Ombudsman for most resident discharges, sending only AMA discharges instead of all discharges. The SW said she was instructed by the Administrator to report only AMA cases and did not know all discharges had to be sent, while the ADON and Administrator also stated they were unaware of the requirement and that the facility did not follow its Transfer and Discharge policy.
A resident with schizoaffective disorder, dementia, severe cognitive impairment, and documented behavioral issues was discharged to another facility without receiving the required written notice of transfer or discharge, including reasons for the move and related rights. The DON and ADM confirmed that only verbal notice was given to the responsible party, despite acknowledging that important information can be forgotten if not provided in writing. Facility policy on transfers and discharges did not specify the need for formal written notice when health and safety concerns prompted an urgent discharge.
A resident with dementia, multiple chronic conditions, and impaired communication was transferred to a hospital for stroke-like symptoms, but the responsible LVN did not complete required change-of-condition and discharge documentation. Family reported they were not officially notified by the facility of the resident’s change in condition or transfer, and staff interviews confirmed there were no timely clinical notes detailing the reason for transfer, physician and family contacts, or how and when the resident left. The interim DON and ADM stated that the absence of an SBAR prevented the discharge summary from being generated and kept the discharge from appearing on the ADT report until a discharge summary was completed later after surveyor intervention.
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