Failure to Provide Written Discharge and Bed Hold Policy Information During Hospital Transfers
Penalty
Summary
The facility failed to provide required written documentation regarding the reason for discharge and the bed hold policy, including cost information, to residents and their representatives during hospital transfers. For four residents with complex medical histories, including conditions such as spina bifida, diabetes, congestive heart failure, dementia, and stroke, there was no evidence in the clinical records that written notices or bed hold policy details were given at the time of transfer. In several cases, nursing notes documented the transfer to the hospital but did not indicate that the residents or their representatives received the necessary information. One resident specifically reported not recalling receipt of discharge or bed hold policy documents. Interviews with facility staff, including the DON and Clinical Support Nurse, confirmed that while discharge paperwork was typically sent with the resident to the hospital, there was no documentation in the electronic health record to show that the required information was provided to the residents or their representatives. Facility policies required advance communication of bed hold options and charges, but the records reviewed did not demonstrate compliance with these requirements for the residents transferred to the hospital.