Failure to Provide Timely Bed Hold Notices and Ombudsman Notifications During Resident Transfers
Penalty
Summary
The facility failed to provide required written bed hold notices at the time of hospital transfer for two residents and did not notify the ombudsman for three residents who were hospitalized. For one resident with moderate cognitive impairment, the bed hold notice was not signed or provided within 24 hours of transfer, and the resident was not included in the facility's list of those leaving the building. Documentation showed the bed hold notice was signed several weeks after the transfer. Additionally, the ombudsman was not notified of this resident's transfer as required. Another resident, who was cognitively intact, left the facility against medical advice, but the facility was unable to provide documentation that the ombudsman had been notified of the discharge. For a third resident, who was transferred to acute care with a return anticipated, there was no documentation that a bed hold was offered or that the ombudsman was notified of the transfer. These failures were confirmed through staff interviews and record reviews, with staff acknowledging the lack of timely notifications and documentation.