Failure to Provide Required Written Transfer/Discharge Documentation
Penalty
Summary
The facility failed to provide written documentation of transfer or discharge, including required bed hold notices and involuntary discharge notifications, for four residents who were transferred or discharged from the facility. In each case, the residents or their representatives did not receive the necessary written information regarding their rights, the facility's bed hold policy, or the reasons for non-admittance, as required by facility policy and federal regulations. Staff interviews revealed a lack of clarity regarding responsibility for providing these documents, with nursing staff, the DON, and social services each indicating it was not their role to issue the notices. One resident with multiple diagnoses, including dementia and chronic kidney disease, was transferred to the hospital due to behavioral issues and was not allowed to return to the facility. The resident's family member expressed that she did not want the resident discharged and would have preferred he remain at the facility while awaiting placement elsewhere. Both the DON and CEO confirmed that no involuntary discharge notice, judiciary petition, or bed hold notification was provided, citing lack of awareness or misunderstanding of the requirements. Other residents were transferred to the hospital for medical reasons such as lethargy, wound care, and complications related to chronic conditions. In each instance, staff provided paramedics with medical documents but did not issue written bed hold notices to the residents or their representatives. Staff interviews consistently indicated that the responsibility for providing these notices was unclear, and the facility was unable to produce any documentation showing that the required notifications had been given.