Failure to Communicate Transfer Information, Bed-Hold Policy, and Ombudsman Notification
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider during facility-initiated transfers for two residents. Specifically, there was no documented evidence that the residents' care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the residents' specific needs were provided to the receiving facility upon transfer. This deficiency was confirmed by the DON during interviews and was evident in the clinical records of the affected residents, who had complex medical histories including diabetes, hypertension, chronic kidney disease, cerebral infarction, and muscle weakness. Additionally, the facility did not provide written notification of the bed-hold policy to the residents or their representatives at the time of hospital transfer for three residents. The clinical records lacked documentation of this required notification. Furthermore, the facility failed to notify the Office of the State Long-Term Care Ombudsman upon transfer to the hospital for these residents, as confirmed by the DON and a review of facility records. These failures were identified through policy review, clinical record review, and staff interviews.