Failure to Provide Bed Hold Notices and Written Transfer Notifications
Penalty
Summary
The facility failed to provide required documentation and notifications related to bed-hold policies and transfer notifications for two residents who were hospitalized. For one resident with multiple chronic conditions, including COPD, respiratory failure, diabetes, anxiety disorder, and congestive heart failure, the facility did not provide a Bed Hold Notice to the resident or her representative upon transfer and admission to the hospital on two separate occasions. The resident's medical record and care plan indicated significant dependence on staff for daily activities and medication management, but there was no documentation that the bed hold policy or notice was given at the time of her hospitalizations. Another resident, who had severe cognitive impairment, multiple sclerosis, seizures, respiratory failure, pneumonia, pressure ulcers, and required a G-tube and supplemental oxygen, was transferred multiple times to an acute hospital with a return anticipated. The facility failed to provide the required written notification of transfer to this resident or his representative for each of these facility-initiated discharges. The resident's records documented repeated unplanned discharges and re-entries, but there was no evidence that the mandated notifications were provided as required by policy. Interviews with administrative staff confirmed that the facility had not been consistently providing bed hold notices or written notifications of transfer as required. The facility's own policies stated that residents and their representatives should be informed of the bed hold policy prior to transfer and receive written notification of transfer or discharge, but these procedures were not followed in the cases reviewed.