Missing transfer notices, bed-hold documentation, and ombudsman notification: The facility did not provide complete transfer paperwork for several residents sent to the hospital. Surveyors found transfer notices that lacked the specific reason for transfer, and for two residents there were no bed-hold forms or documentation that the ombudsman was notified. The residents had significant medical conditions, including CKD, DM2, COPD, CHF, hemiplegia, and respiratory failure.
A facility failed to provide transfer notices with a specific reason for transfer for multiple residents, including residents transferred for sepsis/cellulitis, UTI, hyperkalemia, COVID infection, and wound or fall-related hospitalizations. The notices used general language about urgent medical needs or welfare needs instead of the actual basis for transfer, and the Ombudsman notifications for several hospital transfers were delayed for weeks or months. The Social Services Manager stated notifications were usually sent monthly and could not recall why some were delayed.
Failure to provide bed-hold notice after hospital transfer: A resident with recurrent falls and a hip fracture was transferred to the ED after acute changes in condition and later admitted to the hospital. The facility did not provide or document written bed-hold information for the resident or representative, and although the BOM said a phone call was made to the wife and she declined to hold the bed, that conversation was not documented in the chart.
A resident with vascular dementia, diabetes, and right-side paralysis, and with severely impaired cognition and an activated POA for healthcare, was transferred to another SNF without prior notification or involvement of the POA in discharge planning, contrary to the facility’s own admission agreement and procedures. The resident’s record contained only a physician-signed discharge order with no resident or representative signature, no documented discharge communication, and no recapitulation of stay. The social services/discharge coordinator confirmed they did not contact the POA or obtain required signatures, and the administrator acknowledged the discharge process was not carried out according to facility policy.
Failure to Notify Ombudsman of Hospital Transfers and Discharges: The facility did not ensure the State LTC Ombudsman was notified of multiple resident hospital transfers/discharges. A monthly discharge/transfer report used for notification did not include several residents who were sent to the hospital after changes in condition, including residents with diagnoses such as colon cancer, dementia, CKD, anemia, heart disease, diabetes, stroke, and acute renal failure. The NHA and SWD stated the report being sent did not capture all residents transferred or discharged to the hospital.
A resident was accepted for admission from a hospital with the understanding that she was a pivot transfer, but upon arrival she was placed in a too-small wheelchair, slid to the floor when reaching down, and was sent to the ED by EMS because staff could not get her up. The facility’s record contained only pre-admission documents and lacked admission notes, assessments, incident documentation, or discharge records. Leadership acknowledged that no admission paperwork was completed and that the facility lacked appropriate bariatric equipment, yet there was no documented assessment of transfer status, no evidence that the resident or representative received required written transfer/discharge notices, appeal rights, Ombudsman contact information, or bed-hold and return-rights information, and no documented communication with the hospital explaining the reason for discharge or confirming re-admission.
Incomplete Transfer/Discharge Notices: The facility did not ensure that two residents or their representatives received proper written transfer/discharge notices with a specific reason for transfer and required Ombudsman information. Review found the forms used only general options such as resident choice or urgent medical need, and the notices for both residents’ hospitalizations did not state a specific reason for the move.
The facility failed to provide required written transfer/discharge notices, bed-hold notices with the per diem rate, and Ombudsman notifications for multiple residents. Records showed several hospital transfers and one discharge without evidence of the required notices, and some bed-hold forms were incomplete. Staff stated Ombudsman notifications had not been sent for months, and one resident with a guardian had notices signed by the resident instead of the guardian.
The facility failed to provide written transfer and bed hold notices for two residents who were sent to the hospital. One resident with intact cognition was transferred after a fall, and another resident with intact cognition and an activated POA was hospitalized twice for low blood pressure and later chest pain and difficulty breathing. Survey review found no written transfer or bed hold notices in either record, and staff described a process of sending forms with the resident or giving verbal notice, while also stating that Medicaid residents typically did not receive a bed hold agreement.
Two residents were transferred to the hospital and did not receive proper written bed-hold and transfer/discharge notices with required appeal rights information. One resident with metastatic cancer, chronic pain, a stage 4 pressure ulcer, and moderate cognitive impairment, represented by an activated POA, was told by the admissions staff that the resident was being kicked out and would not be allowed to return, and neither the resident nor the POA received any written bed-hold or transfer/discharge notice. Another resident with acute on chronic combined systolic and diastolic CHF and aspiration pneumonia, who was cognitively intact and made their own healthcare decisions, signed a bed-hold/transfer form that lacked mandated appeal rights details, including contact information for the appeals entity and instructions on obtaining and submitting an appeal. The DON acknowledged that the facility used the bed-hold form as its policy, had no separate policy, and was unaware of the requirement to include appeal rights on these notices.
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