Failure to Provide Written Notification of Hospital Transfer Reason
Penalty
Summary
Facility staff failed to provide written notification to a resident and their representative regarding the specific reason for the resident's transfer to an acute care hospital. According to the facility's Bed-hold Agreement policy, a copy of the bed-hold agreement, including the specific reason and basis for the transfer, must be provided to the resident or their representative at the time of transfer. Record review showed that for two separate hospital transfers, the bed-hold agreements were signed by the Social Services Designee but did not include the reason for the transfers. The resident involved had multiple diagnoses, including Influenza A, COPD, chronic respiratory failure, cognitive communication deficit, fracture of the neck of the left femur, iron deficiency anemia, schizophrenia, bipolar disorder, hypertension, and dementia. The resident was assessed as cognitively intact at the time of the deficiency. Interviews with the Social Services Designee confirmed that the required written notification of the reason for transfer was not provided to the resident or their representative, and that the bed-hold agreement was not sent at the time of transfer as required.