Failure to Provide Bed-Hold Policy Notification and Notify Ombudsman of Transfers
Penalty
Summary
The facility failed to provide written notice of its bed-hold policy to residents and/or their representatives at the time of transfer for four out of six residents reviewed who were hospitalized. Federal regulations require that residents receive two notices regarding bed-hold policies: one at admission and another at the time of transfer, or within 24 hours in the case of emergency transfers. Documentation for Residents R6, R89, R123, and R138 did not include evidence that this written notification was given at the time of their respective transfers to the hospital, despite clinical records showing that these residents experienced significant medical events such as falls, cognitive impairment, and acute illness leading to hospitalization. Additionally, the facility failed to notify the State Ombudsman Office of resident transfers and discharges over a period spanning from November 2023 through April 2025. This omission was confirmed by both a review of facility documentation and information provided by the State Ombudsman Office, which indicated that no notifications had been received during this time frame. The facility's own policy, as well as federal and state regulations, require timely notification to the Ombudsman Office regarding such resident movements. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed these failures, acknowledging that written bed-hold notifications were not provided to the affected residents or their representatives at the time of transfer, and that required notifications to the State Ombudsman Office were not made for an extended period. The deficiencies were identified through review of facility policies, clinical records, and staff interviews.