Failure to Provide Bed Hold and Transfer/Discharge Notices During Hospitalization
Penalty
Summary
The facility failed to provide required written bed hold notices and transfer/discharge notifications to a resident and her legal guardian during two separate hospitalizations. The resident, who was cognitively intact and had a legal financial guardian, was transferred to the hospital on two occasions due to hypoglycemia, seizure-like activity, chest pain, and coughing. Upon review of the resident's chart, there was no documentation that bed hold notices or transfer/discharge notices were given to either the resident or her guardian for either hospitalization event. Interviews with facility staff, including an LPN, the Nursing Home Administrator, and the Director of Nursing, confirmed that the necessary paperwork was not located in the resident's record and that staff could not recall if the required notifications were provided. The facility's own policies require that bed hold and transfer/discharge notices be given to residents and/or their representatives at the time of transfer, and that documentation of these actions be maintained in the medical record. However, these procedures were not followed in this case, as verified by staff and policy review.