Failure to Provide Bed Reserve Notification During Involuntary Transfer
Summary
The facility failed to provide a Bed Reserve Notification to a resident (R1) during an involuntary transfer to a hospital, as required by their policy. R1, who has a medical history of opioid dependence and mental and behavioral disorders, was involuntarily discharged on 6/3/2024 after exhibiting aggressive behavior towards the Social Service Director (V4) when informed that his community pass was revoked. This incident was not the first, as R1 had a previous involuntary discharge in April of the same year. The facility's policy mandates that a Bed Reserve Notification be given to residents at the time of transfer, but this was not documented or provided to R1. Interviews with facility staff, including the Social Worker (V5) and the Social Service Director (V4), revealed that R1 was not informed about the bed hold policy, which allows a 10-day period for the resident to return to the facility. The facility's policy on Bed Reserve, dated 2008, and the Notice of Bed Hold and Return, dated 11/20/2017, both require that residents be given written notice of the bed hold policy at the time of transfer. However, there was no documentation in R1's progress notes for April, May, and June 2024 indicating that such notice was provided, leading to a deficiency in the facility's adherence to its own policies and federal regulations.
Penalty
The facility failed to provide bed-hold notifications for three residents transferred to the hospital. A resident with multiple diagnoses was transferred due to high blood pressure and fever, another due to low hemoglobin levels, and a third with pneumonia and Flu A. In each case, no bed-hold notice was issued, as confirmed by the Corporate Administrator.
A facility failed to mail a bed hold letter to a resident's POA during a hospital transfer. The resident had severe cognitive impairment and multiple medical conditions, requiring significant assistance with daily activities. The oversight was confirmed by both the POA and the Business Office Manager during interviews.
The facility failed to provide timely and complete bed-hold notifications to several residents, affecting their awareness of remaining bed-hold days. This deficiency was confirmed through interviews and record reviews, highlighting a lack of communication and documentation for residents who were cognitively intact and had various medical conditions.
The facility failed to provide bed hold notices to residents or their representatives at the time of hospital transfer, affecting four residents. The facility's policy requires written notice specifying the bed-hold duration and return information, but this was not documented for residents transferred for medical reasons such as shortness of breath and abnormal lab values. The Administrator confirmed the oversight.
The facility failed to provide timely written bed hold notices to residents or their representatives before hospital transfers, affecting three residents. One resident with multiple health issues was transferred due to low oxygen levels, and the notice was signed post-return. Another resident requested hospital transfer for pain, with the notice signed after return. A third resident with respiratory and heart conditions was transferred, and the notice was delayed until after return. The DON and ADON confirmed these delays, indicating a systemic issue.
The facility failed to provide bed hold notices to two residents before their hospital transfers. One resident, with multiple serious diagnoses, was transferred four times without receiving a notice, as the Business Office Manager only issued notices to Medicaid residents. Another resident with end-stage renal disease was also transferred without a notice, contrary to the facility's policy.
Failure to Provide Bed-Hold Notifications for Resident Transfers
Penalty
Summary
The facility failed to provide bed-hold notifications to residents or their representatives when residents were transferred out of the facility, affecting three residents. Resident #24, who was cognitively intact, was transferred to the emergency room due to not feeling well, with symptoms including high blood pressure and fever. Despite the transfer, there was no evidence of a bed-hold notice being given. This was confirmed by the Corporate Administrator. Resident #50, who was moderately cognitively impaired and used a walker, was taken to the hospital by family due to low hemoglobin levels and returned after receiving a blood transfusion. Similarly, no bed-hold notice was provided for this transfer. Resident #71, with diagnoses including metabolic encephalopathy and dementia, was transferred to the hospital with pneumonia and Flu A, but again, no bed-hold notice was issued. The lack of bed-hold notifications for these transfers was verified by the Corporate Administrator.
Failure to Notify POA of Bed Hold for Resident
Penalty
Summary
The facility failed to ensure that a bed hold letter was mailed to the Power of Attorney (POA) for a resident who was transferred to a hospital or on therapeutic leave. This deficiency affected one resident out of three reviewed for notification of bed hold, within a facility census of 95. The resident in question had a range of medical conditions, including aphasia following cerebral infarction, Parkinson's disease, type two diabetes mellitus, chronic kidney disease, and muscle wasting and atrophy. The resident's medical record indicated severe cognitive impairment and dependency on staff for various activities of daily living. Despite these conditions, the bed hold notice was not sent via certified mail to the resident's POA, as confirmed by both the POA and the Business Office Manager during interviews. This oversight was identified during the investigation of a specific complaint.
Failure to Provide Timely Bed-Hold Notifications
Penalty
Summary
The facility failed to provide timely and complete bed-hold notifications to residents or their representatives, affecting four out of six residents reviewed for bed-hold notices. Resident #16, who was cognitively intact, left the facility multiple times on leave of absence but was not informed of the remaining bed-hold days until after several absences. Similarly, Resident #18, also cognitively intact, was sent to the hospital and returned without being informed of the remaining bed-hold days, and the notice was only provided upon their return. Resident #45, who was cognitively intact, did not receive a bed-hold notice, and there was no evidence of notification regarding the remaining bed-hold days. Resident #11, with a history of cerebral palsy and other conditions, was discharged to the hospital and returned without being informed of the remaining bed-hold days. The facility's failure to provide the number of remaining bed-hold days and timely notifications was verified through interviews with the Social Work Director, who confirmed the deficiencies in communication and documentation for these residents.
Failure to Provide Bed Hold Notices at Time of Transfer
Penalty
Summary
The facility failed to provide bed hold notices to residents or their representatives at the time of transfer to a hospital, as required by their policy. This deficiency was identified during a review of medical records, staff interviews, and policy review. Four residents were affected by this oversight, as there was no documentation of bed hold notices being provided at the time of their transfer to the hospital. The facility's policy, revised in September 2024, mandates that a written notice specifying the duration of the bed-hold policy and information about the resident's return to the next available bed should be given at the time of transfer. The specific cases involved residents who were transferred to the hospital for various medical reasons, including shortness of breath, abnormal laboratory values, and changes in condition. Interviews with the facility's Administrator confirmed that the bed hold notices were not provided to the residents or their representatives at the time of transfer. This issue affected all four residents reviewed for transfer/discharge, and the facility had identified a total of 12 residents sent to the hospital in the past 90 days, with a census of 75.
Failure to Provide Timely Bed Hold Notices
Penalty
Summary
The facility failed to provide written bed hold notices to residents or their representatives prior to hospital transfers, affecting three residents. Resident #71, who had multiple diagnoses including diabetes and chronic kidney disease, was transferred to the hospital due to low oxygen levels and returned to the facility without a signed bed hold notice until after readmission. The Director of Nursing confirmed the notice was signed post-return. Resident #61, with conditions such as chronic obstructive pulmonary disease and schizophrenia, requested hospital transfer due to pain and swelling. The bed hold notice was signed after the resident's return, contrary to policy. Similarly, Resident #106, with diagnoses including respiratory failure and heart failure, was transferred to the hospital, and the bed hold notice was signed upon return. The Assistant Director of Nursing verified the delay in signing the notice, indicating a systemic issue in adhering to the facility's bed hold policy.
Failure to Provide Bed Hold Notices Before Hospital Transfers
Penalty
Summary
The facility failed to provide bed hold notices to two residents, Resident #52 and Resident #82, prior to their transfers to the hospital. Resident #82, who had multiple diagnoses including metabolic encephalopathy and respiratory failure, was discharged to the hospital on four occasions without receiving a bed hold notice. The Business Office Manager admitted that bed hold notices were only given to Medicaid residents, which resulted in Resident #82 not receiving the required notice. Additionally, a family member of Resident #82 confirmed that they did not recall receiving any bed hold notice during the hospital transfers. Similarly, Resident #52, who had diagnoses such as end-stage renal disease and heart failure, was transferred to the hospital without a bed hold notice being provided. The Business Office Manager confirmed that Resident #52 did not receive a bed hold notice at the time of transfer. The facility's policy, dated September 2021, stated that a copy of the bed hold policy should be provided to the resident and their family or legal representative before and during a transfer for hospitalization or therapeutic leave, which was not adhered to in these cases.
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