Failure to Provide Required Bed Hold Notices and Ombudsman Notifications During Hospital Transfers
Penalty
Summary
The facility failed to provide required documentation and notifications related to residents' needs, appeal rights, and bed-hold policies during instances of discharge or transfer to the hospital. Specifically, the facility did not issue appropriate bed hold notices to residents or their representatives and did not notify the Ombudsman when residents were transferred or discharged to the hospital. This deficiency was identified through medical record reviews and staff interviews, affecting four out of five residents reviewed for discharge and hospitalization. For example, one resident with acute on chronic diastolic heart failure was discharged to the hospital and did not return, but there was no documentation of Ombudsman notification. Another resident with right hip fracture and osteomyelitis was transferred to the hospital twice, with no Ombudsman notification documented for either transfer. Additional cases included residents with hypothyroidism, cardiomegaly, atrial fibrillation, diabetes, schizoaffective disorder, and chronic kidney disease, where bed hold notices were not provided and Ombudsman notifications were not documented. Staff interviews confirmed these failures in documentation and notification.