Failure to Provide Required Transfer/Discharge and Bed-Hold Notifications
Penalty
Summary
The facility failed to provide required written notifications of transfer or discharge, including bed-hold policies and appeal rights, to residents, their representatives, or the ombudsman for two residents who were hospitalized. For one resident with end stage renal disease, respiratory failure, and atrial fibrillation, there was no documented evidence of discharge notices or bed-hold notifications for three separate hospitalizations, nor was there evidence that the ombudsman was notified of one of these hospitalizations. The facility's policy requires that such notifications be provided in writing and in a language and manner understood by the resident and their representative, and that the ombudsman be notified at the same time as the resident and representative. For another resident with diagnoses including sepsis, viral encephalitis, and chronic lymphocytic leukemia, there was no documented evidence of a discharge notice or bed-hold notification when the resident was sent to the hospital. Additionally, the resident's family member, listed as the emergency contact, reported not being contacted by the facility regarding the hospitalization and only learned of it from the hospital. These findings were confirmed through interviews and record reviews, which revealed the absence of required documentation in the medical records for both residents.