Failure to Provide Required Written Notification of Bed-Hold Policy and Appeal Rights During Hospital Transfers
Penalty
Summary
The facility failed to provide required written notification and information regarding bed-hold policies, appeal rights, and contact information for advocacy agencies to residents and/or their representatives when residents were transferred to the hospital. This deficiency was identified for three out of four sampled residents who were hospitalized. The facility's own policies required that, prior to transfer, residents and their representatives be informed in writing of the bed-hold and return policy, as well as their appeal rights and contact information for the Ombudsman and relevant advocacy agencies. For one resident with moderate cognitive impairment and multiple medical diagnoses, including diabetes, dementia, and respiratory failure, the record showed that the resident was transferred to the hospital after a significant change in condition. However, the facility was unable to provide evidence that the required Notice of Transfer/Bed Hold was sent to the resident or their representative. Interviews with facility staff revealed that the process for triggering the notification was not consistently followed, as the necessary documentation in the electronic health record was not completed by the responsible nurses. Similar deficiencies were found for two other residents, one with moderate cognitive impairment and intellectual disabilities, and another with severe cognitive impairment and multiple medical conditions. In both cases, the facility could not provide evidence that the residents or their representatives received complete information regarding their rights, the bed-hold policy, or contact information for advocacy agencies at the time of hospital transfer. Staff interviews confirmed that the required notifications were not sent due to incomplete documentation and lack of adherence to established procedures.