Failure to Provide Required Transfer Notifications and Bed-Hold Policy Information
Penalty
Summary
The facility failed to provide required written notifications and documentation related to transfers or discharges for five residents who were transferred to hospitals. Specifically, there was no evidence in the medical records that written notifications of transfer or the facility's bed-hold policy were given to the residents or their responsible parties prior to or at the time of transfer. This deficiency was identified for multiple residents who had been transferred out of the facility on several occasions, as confirmed through interviews with the residents and review of their medical records. Additionally, the facility did not have a system in place to notify the Office of the State LTC Ombudsman of these transfers, as required by policy. Interviews with the DON and the Regional Clinical Consultant RN confirmed the absence of documentation and processes for providing written transfer notifications, bed-hold policy information, and ombudsman notifications. Facility policies reviewed indicated that such notifications should be provided at admission and before hospital transfers, but these procedures were not followed for the residents involved.