Failure to Provide Required Transfer/Discharge Notices and Ombudsman Notification
Summary
The deficiency involves the facility’s failure to provide required transfer/discharge notices to residents and to send copies of those notices to the Office of the State Long-Term Care Ombudsman for multiple residents. Surveyors found that the facility relied on the Notice of Medicare Non-Coverage (NOMNC) as its only discharge/transfer notice and did not use any separate form that met regulatory content requirements. The NOMNC used by the facility did not include the effective date of transfer/discharge, the location to which the resident would be transferred or discharged, the name, address, and telephone number of the State Long-Term Care Ombudsman, or contact information for protection and advocacy agencies for individuals with developmental disabilities or mental disorders. Staff interviews confirmed that the Resident Relations Manager and Business Office Manager considered the NOMNC to be the facility’s discharge/transfer notice and that they did not provide ombudsman information to residents or send copies of discharge/transfer notifications to the ombudsman. For Resident #107, who had hemiplegia and hemiparesis following cerebral infarction, systolic congestive heart failure, muscle issues, and gait and mobility abnormalities, the physician documented that the resident would transfer to another SNF at the family’s request, and a subsequent note showed the resident was discharged via transport van. The discharge MDS documented an unplanned discharge to a SNF. However, review of the clinical record revealed no evidence that a discharge notification was sent to the State Long-Term Ombudsman. The facility’s Admissions, Transfers and Discharges policy referenced reporting information in accordance with facility policy and professional standards but did not include requirements for notifying the ombudsman. For Resident #8, admitted with COPD, palliative care, and paroxysmal atrial fibrillation, the care plan included goals for pre-discharge planning. A discharge order and a discharge-transfer note/summary documented discharge home with oxygen equipment, home health services, narcotic medications, and a scheduled PCP appointment, and this summary was signed by the resident’s family. The documentation given to the family did not include the ombudsman’s contact information or an explanation of appeal rights. The discharge MDS showed an unplanned discharge home with return not anticipated, and there was no evidence in the clinical record that the ombudsman was notified of the discharge. An email sent about 19 days after discharge contained only a list of residents who were discharged, deceased, or transferred, and for this resident it listed a discharge/transfer to another hospital without the reason for discharge or the same information provided to the family. For Resident #12, admitted with atherosclerotic heart disease, the discharge MDS documented an unplanned discharge to hospice at home. A discharge/transfer/LOA form indicated discharge to the community with hospice services at a private home/apartment, initiated by the resident or representative, and a discharge summary and progress note documented discharge home with belongings, medications, and paperwork. There was no physician order for discharge in the order summary report, and the clinical record did not show that a copy of the discharge notification was sent to the ombudsman. In an interview, the Resident Relations Manager stated that a copy of the notification is not sent to the ombudsman and that ombudsman information is not provided to residents. For Resident #100, admitted with COPD, an order directed transfer to the ED for shortness of breath, and a discharge summary documented respiratory distress and transport via ambulance to an acute care hospital. A social services note stated that the resident or representative was provided written notice of transfer, bed-hold notice, readmission policy, ombudsman and appeals information. However, the clinical record contained no evidence that a copy of the transfer notice was sent to the State Long-Term Care Ombudsman. For Resident #102, admitted and later readmitted with hepatic encephalopathy, influenza, and cirrhosis, clinical documentation showed an anticipated discharge to the community, an NP note indicating discharge to prior living arrangements, and an unplanned discharge home/community on the MDS. A discharge/transfer/LOA form and discharge summary documented discharge to a private home/apartment without hospice, initiated by the resident or representative, and a social services note recorded that the family picked the resident up and took him back to the reservation. There was no physician discharge order, and no indication in the record that a copy of the discharge notification was sent to the ombudsman. Interviews with the ombudsman and facility staff further described the deficient practice. The ombudsman reported that their office previously received a list of discharged/transferred residents but had not received anything for recent months and that they were sent only a list, not copies of discharge/transfer notifications. The Resident Relations Manager and Business Office Manager stated that Resident Relations is responsible for presenting the notice of proposed discharge/transfer, that the notice is presented up to 72 hours prior to discharge, and that a copy of the notification is not sent to the ombudsman. They also stated they were unsure if any policy or guidance outlined what information must be included in the notice and confirmed that the NOMNC was the only form used as a discharge/transfer notice, even though it lacked ombudsman and advocacy contact information. The acting DON reported being unfamiliar with discharge/transfer notification requirements, and the Executive Director stated that the facility used only the NOMNC, believed no paper notice was required beyond that, and understood the facility’s obligation as sending a monthly list of discharged/transferred residents to the ombudsman, not copies of the actual transfer/discharge notifications.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with paraplegia, multiple chronic conditions, colostomy, urostomy, indwelling catheter, and multiple pressure and diabetic ulcers was discharged home despite being totally or largely dependent for ADLs, transfers, and complex wound and ostomy care. Care plans and MDS data showed the resident required extensive assistance, and MAR/TAR review revealed some wound and skin treatments were undocumented on at least one day before discharge. The record contained no documentation that the resident was educated on ostomy management or how his ADL needs would be met at home. Home health was arranged only for intermittent skilled nursing and therapy, without a home health aide, and the resident’s Medicaid waiver services had been lost, leaving his blind, developmentally disabled spouse as the primary caregiver. Staff interviews confirmed the resident had not been taught to manage his own care and relied on staff for bathing, transfers, and ostomy and wound care, leading surveyors to determine the facility failed to ensure a safe discharge.
Surveyors found that the facility failed to ensure a comprehensive discharge process for a resident with multiple complex conditions and an active plan to return to the community, as the care plan was not updated to reflect discharge planning, the discharge summary lacked a reconciled medication list, and there was no documented evidence that prescriptions were accurately provided or transmitted at discharge. In addition, another cognitively intact resident who was transferred to the hospital and later readmitted had no documentation that they or their representative received a required bed-hold notice or were offered the option to hold the bed, contrary to facility policy.
The facility failed to provide required bed-hold notifications to two long-term residents and/or their representatives when the residents were transferred to the hospital after changes in condition. One resident with atherosclerotic heart disease, post-laminectomy syndrome, and cognitive impairment, and another with heart failure, pulmonary fibrosis, dysphagia, and memory problems, were both dependent on staff for ADLs and had designated representatives or POAs. For multiple hospital transfers, their medical records contained no documentation of bed-hold notices detailing remaining covered bed-hold days, despite the Admissions Director’s statement that such notices are given and filed, and despite a facility policy requiring a bed-hold letter and policy at admission and with each discharge or transfer.
A resident discharged with multiple medical conditions, including dysphagia and hypertension, did not have a signed discharge summary verifying receipt of wound care instructions, even though the form required a resident or responsible party signature. Record review showed the resident was cognitively intact and required set-up to moderate assistance with ADLs at discharge, yet no signature was present. An RN confirmed she did not obtain the resident’s signature, and leadership later identified that nurses were not consistently obtaining required signatures on discharge summaries, resulting in a cited deficiency related to the discharge process.
A resident with multiple medical conditions, moderately impaired cognition, and a court-appointed guardian was discharged home without guardian approval and with HHC arranged only on the day of discharge. Documentation showed the resident required assistance with ADLs and had functional decision-making impairments, yet social services recorded that the resident insisted on going home, refused LTC placement, and arranged transportation with a family member. Discharge notes indicated instructions and medications were provided, but interviews confirmed that the guardian did not authorize the discharge and that the timing of the HHC referral did not follow the facility’s usual practice, resulting in a failure to ensure a safe and orderly discharge as required by facility policy.
A resident who was cognitively intact and required supervision with ADLs was discharged AMA at the request of a representative, and an LPN mistakenly sent home another resident’s medications and discharge instructions. The error was discovered at shift change when staff could not locate the other resident’s medications, and the discharged resident’s representative later reported the issue to police and returned the incorrect medications and paperwork. The Administrator and DON stated staff realized the error a few hours after discharge, and facility policy required a discharge planning process to ensure a safe transition that met the resident’s needs.
Failure to Ensure Safe Discharge for Highly Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe and adequately planned discharge for Resident #62, a cognitively intact but highly dependent resident with extensive medical and functional needs. The resident had multiple serious diagnoses, including osteomyelitis, spina bifida with paraplegia, cauda equina syndrome, chronic myeloproliferative disease, chronic kidney disease, peripheral vascular disease, chronic myeloid leukemia, Arnold Chiari syndrome, glaucoma, type 2 diabetes with a foot ulcer, urinary incontinence, repeated falls, and pressure ulcers. Care plans documented that the resident was totally dependent for many ADLs, including putting on and taking off footwear, required setup and cleanup for eating and oral hygiene, and needed supervision or assistance for bed mobility, transfers, toileting, showering, and lower body dressing. The resident also had a colostomy, urostomy, indwelling catheter, and multiple wound care needs, with care plans addressing ostomy management and wound treatments to the sacrum, buttocks, and feet. Record review showed that the facility had multiple treatment orders for wound care, ostomy care, catheter care, and skin protection, with documentation on the MAR/TAR indicating some missed or undocumented treatments on at least one day prior to discharge. The discharge MDS indicated the resident remained dependent or required at least partial to substantial assistance for toileting hygiene, lower body dressing, transfers, bathing, and personal hygiene, and used a manual wheelchair. Despite this high level of dependence, there was no documented evidence in the closed record that the resident was educated on ostomy management prior to discharge, nor any documentation describing how his extensive ADL needs would be met at home. Interviews with nursing staff confirmed that they did not provide education on care or medications, and that the resident required assistance with bathing, transfers, ostomy care, and wound care, with nurses performing dressing changes and medication administration and CNAs assisting with transfers and hygiene. Discharge planning notes showed that social services initially discussed discharge with the resident and a developmental disabilities care manager, with an expectation that Passport Medicaid Waiver caregiver services and wound care services would continue at home. However, interviews and an email from the home health agency later confirmed that the resident’s Medicaid waiver had been lost prior to discharge, and the home health services arranged were limited to skilled nursing and therapy without a home health aide. The home health agency reported providing skilled nursing twice weekly for a foot ulcer and that a third-party wound specialist managed the buttocks wound, while the resident’s wife was identified as the primary caregiver. Post-discharge interviews with the resident’s wife, her caregiver, and the resident’s power of attorney revealed that the wife was blind and developmentally disabled, that the resident no longer had waiver services or a caregiver to assist with daily care, and that he was unable to bathe or manage his colostomy and wound care independently, resulting in frequent soiling and inability to clean himself. The administrator confirmed the waiver was not available at discharge, and the social worker designee acknowledged she had believed the waiver was in place earlier and later learned it had been lost, yet the record contained no documentation of how the resident’s ADL and complex care needs would be safely managed at home. These actions and omissions led to the finding that the facility failed to ensure a safe discharge for Resident #62.
Failure to Ensure Comprehensive Discharge Planning and Bed-Hold Notification
Penalty
Summary
The deficiency involves the facility’s failure to ensure a comprehensive and accurately documented discharge process for one resident. A cognitively intact resident with multiple complex diagnoses, including hypertension, anxiety, cerebral infarction, peripheral vascular disease, gangrene, cardiomyopathy, diabetes, and other conditions, was discharged home after their health had improved sufficiently for a less skilled level of care. The resident’s care plan identified them as a long-term placement due to needs exceeding community resources and was not revised to reflect the facility’s active discharge planning back to the community, despite the MDS indicating an active discharge plan. The discharge planning care plan was only cancelled after the resident had already been discharged, with no documented updates showing the planned transition to home. At discharge, nursing documentation stated that discharge instructions were reviewed and that medications and prescriptions were provided as ordered. However, the discharge summary contained no evidence of the specific medications or prescriptions reviewed at discharge and no documented medication reconciliation for accuracy. The section of the discharge summary designated for post-discharge medications contained only a handwritten note stating “See List,” but no medication list was attached. The closed medical record did not contain copies of prescriptions or evidence of the medication orders being faxed to the pharmacy or provided to the resident on the day of discharge. Subsequent documentation showed that the resident’s power of attorney later reported that the prescriptions had not been received by the pharmacy, and the facility confirmed that the pharmacy had not received them, leading to a refax several days after discharge. The administrator confirmed that the discharge planning care plan lacked revisions reflecting the planned discharge back to the community and that the prescriptions had initially been faxed to a different number. Additionally, for another cognitively intact resident who was transferred to the hospital and later readmitted after a seven-day ICU stay, the record contained no documentation that the resident or their representative was given a bed-hold notice or the option to hold the bed or not at the time of transfer, despite facility policy requiring a bed-hold notice to be completed, delivered, and documented at the time of transfer.
Failure to Provide Required Bed-Hold Notifications for Hospital Transfers
Penalty
Summary
The deficiency involves the facility’s failure to provide required bed-hold notifications to residents and/or their representatives upon transfer to the hospital. One resident was a long-term male resident with atherosclerotic heart disease, post-laminectomy syndrome, hypertension, impaired upper extremities, and dependence on staff for ADLs. His MDS showed a BIMS score of seven, indicating he was alert and oriented with cognitive impairment, and he had a designated representative and care conference contact. He was sent to the hospital via emergency services after a change in condition, but his medical record did not contain any documentation that bed-hold notifications of days remaining were provided to him or his representative at the time of this discharge/transfer. Another long-term female resident with heart failure, pulmonary fibrosis, dysphagia, memory problems, and dependence on staff for ADLs was also affected. She had a designated POA, representative, and care conference contact, and was ultimately discharged from the facility. Progress notes documented that she was sent to the hospital via emergency services on two separate occasions after changes in condition. However, her medical record lacked bed-hold notifications of remaining days for both hospital transfers. During an interview, the Admissions Director stated that residents on Medicaid who were sent to the hospital and expected to return should receive a bed-hold notice and that all such notices and policies were kept in the medical record. The Admissions Director reported that this resident and later her POA were informed of remaining bed-hold days for all transfers, but upon review of the record, confirmed there were no bed-hold notifications for the two identified hospitalizations, despite a facility policy requiring provision of a bed-hold letter and policy upon admission and any subsequent discharge or transfer.
Failure to Obtain Resident Signature on Discharge Summary and Instructions
Penalty
Summary
The facility failed to ensure a resident’s discharge summary was signed to verify receipt of discharge instructions, as required by the form. A closed record review showed that Resident #94, admitted with diagnoses including foreign body in the respiratory tract, dysphagia, hypertension, and anxiety, and documented as cognitively intact and needing set-up to moderate assistance with ADLs at discharge, had a discharge summary with wound care instructions that lacked a signature from either the resident or a family member, despite the form indicating a signature should be obtained. During interview, the RN responsible for the discharge confirmed she did not obtain the resident’s signature on the discharge summary, and the Divisional Director of Clinical Education reported that, after reviewing the complaint involving this resident, they found that nurses were not obtaining signatures from residents or responsible parties on discharge summaries. This deficiency affected one of three residents reviewed for the discharge process and was cited under Complaint Number 2667505. The deficiency centers on the absence of documented acknowledgment of discharge and wound care instructions, as evidenced by the unsigned discharge summary for Resident #94, and confirmed through staff interviews and record review.
Failure to Ensure Safe Discharge for Resident Under Guardianship
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe discharge for a resident who had a court-appointed guardian and documented cognitive impairment. The resident, admitted with diagnoses including atrial fibrillation, depression, mental disorder, hemiplegia and hemiparesis following cerebral infarction, and essential hypertension, had a recent MDS showing moderately impaired cognition (BIMS score of eight) and needed assistance with eating, toileting, bathing, and personal hygiene. A Letter of Guardianship documented that the resident was incompetent for an indefinite period. The discharge summary stated the resident was discharged home with functional impairments in decision-making, that the son would provide transportation, and that discharge paperwork was reviewed with the patient. Social service notes on the day of discharge documented that the resident’s daughter had been called regarding a lost appeal, that the resident was to discharge home with HHC and transportation by his son, and later that the resident was discharged home with his brother, with discharge instructions reviewed and paperwork signed. Further review and interviews revealed that the HHC referral for the resident was not sent until the day of discharge, whereas the social service assistant stated such referrals usually occur prior to the day of discharge. The HHC notification showed HHC was planned and accepted on the same day as discharge. The social service assistant and the Administrator confirmed that the resident’s guardian did not give approval for the resident to discharge home and that the resident arranged his own transportation, stating he would call his brother. A subsequent social service note documented that the resident was adamant about returning home and refusing LTC placement or transfer, and that, based on discussion with the resident, there was no evidence he was incompetent to make his own decisions, and that he verbalized the risks of living alone. The facility’s Transfer and Discharge policy required orientation and documentation to ensure a safe and orderly transfer or discharge in a form and manner the resident could understand. The survey found the facility failed to ensure a safe discharge for this resident, who was under guardianship and discharged home without guardian approval, with HHC arranged only on the day of discharge.
Failure to Ensure Safe and Orderly Resident Discharge
Penalty
Summary
The facility failed to provide a safe and orderly discharge for a cognitively intact resident who required supervision with ADLs and had diagnoses including COVID-19, depression, and macular degeneration. The resident was admitted on 09/10/25 and discharged on 09/30/25, leaving against medical advice at the request of the resident’s representative. At discharge, an LPN mistakenly provided the resident’s representative with another resident’s medications and written discharge instructions. The error was not identified until shift change when the night shift nurse could not locate the other resident’s medications in the medication cart. The other resident, admitted on 09/17/25 with diagnoses including cerebral infarction, seizures, and sepsis and with multiple active medication orders, remained in the facility. The resident’s representative discovered that the medications and discharge instructions belonged to a different resident and reported concerns about the resident’s care to the police the following day. The representative informed the police that the facility had acknowledged the error when she called and had asked her to return the medications and discharge instructions so they could be exchanged for the correct ones. A police officer accompanied the representative back to the facility, where the exchange occurred without issue, and the representative confirmed that none of the incorrect medications had been administered to the resident. The Administrator and DON reported that nursing staff realized the error approximately two to three hours after the resident left the facility. Review of the facility’s Discharge/Transfer policy showed that the facility was required to develop and implement a discharge planning process involving the resident or representative and the interdisciplinary team to ensure the resident’s needs were identified and there was a safe transition to a location that met the resident’s needs.
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