Brookhaven Nursing And Rehabilitation Center

2:10PM revealed she was the geriatric social worker at behavioral hospital.

She stated the hospital was an acute stay behavioral hospital that stabilized behavior then discharged patients and it was not for long-term placement.

She stated that Resident#1 was transferred to the hospital to evaluate and establish a medication regimen that would regulate his behavior and there was no clinical discharge summary provided.

Interview with the DON on 11/04/2025 at 3:55pm revealed that she had been employed for a month.

When asked if there was a clinical discharge summary or documentation dated 10/03/2025 the DON stated she could not find any documentation.

She stated that the last week of October 2025 there was an email that SW C had gotten everything that she needed to find Resident#1 a new facility.

She stated it was necessary to provide clinical discharge summary to the receiving hospital for continuum of care.

Interview with LVN A on 11/04/2025 at 4:30PM revealed she was the nurse when Resident#1 was transferred to.

She stated that she was not aware if he signed a discharge notice.

She stated that she did not complete a discharge summary or the E-interact (a set of dashboard checklists, and automatic triggers designed to work together to assist care teams to reduce acute care transfers) because it was a busy day.

She stated that failure to provide discharge summary to the admitting facility could result in the residents not receiving the care they deserve.

Interview with MD on 11/04/2025 at 4.40pm revealed he called the ER and gave report to the ER Doctor and spoke with case management staff and notified them the resident would not be returning to the facility. He stated whenever a Resident transferred to the ER from the nursing home, the facility called and gave report to the receiving hospital. He stated that he did not make a discharge summary, because his duty was to call the hospital and give reports of what was going on with the residents. He stated that the nurse was responsible for the discharge summary.

Interview with SW B on 11/04/2025 at 4.45pm revealed that she did not send clinical documents or complete discharge summary because the former Administrator and the DON oversaw the transfer.

She stated it was important to provide the admitting facility with proper documentation such as clinical discharge summary so the residents can be cared for appropriately.

Interview with Administrator on 11/04/2025 at 4:56PM revealed he was newly hired, and he was not part of the discharge and that he could not speak on how it was overseen. He stated even in an immediate transfer there is procedure and protocol to ensure the receiving facility had enough information to care for the resident. He stated that his expectation was there would be a time and record of when the resident signed and accepted the discharge notice.

Record review of the facility's Transfer or Discharge, Emergency policy, latest revision dated 08/2018, stated the following: If the resident is transferred or discharged despite his or her pending appeal, the danger that failure to transfer or discharge would pose will be documented.Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures:a.

Notify the resident's Attending Physician.b.

Notify the receiving facility that the transfer is being made.c.

Prepare the resident for transfer.d.

Prepare a transfer form to send with the resident.e.

Notify the representative (sponsor) or other family members.f.

Assist in obtaining transportation; andg.

Others as appropriate or as necessary.5.

Should it become necessary to transfer residents during emergency or disaster situations, transfer procedures outlined in our disaster plan will be implemented.6.

The resident's medical record must be forwarded to the Medical Records office within twenty-four (24) hours of the transfer or discharge.

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