Failure to Provide Required Written Notices for Bed-Hold and Transfer/Discharge
Penalty
Summary
The facility failed to follow its own policies and procedures regarding the provision of written notices for bed-hold and transfer/discharge to residents or their representatives upon transfer to a general acute care hospital. Specifically, three residents with significant cognitive and physical impairments were transferred to hospitals, but neither they nor their responsible parties received the required written notifications about bed-hold options or transfer/discharge, as mandated by facility policy. The Director of Nursing (DON) confirmed during interviews that there was no process in place to generate and deliver these written notices within the required timeframe. For one resident with a history of tracheostomy, gastrostomy, hemiplegia, and major depressive disorder, the records showed she was dependent for most activities of daily living and unable to make medical decisions. Although a bed-hold was ordered and a family member requested it, there was no documentation that a written notice of bed-hold or transfer/discharge was provided to the resident or her representative. The family member also confirmed not receiving any written notification or information about the resident's rights or room change at the time of transfer. Two additional residents, one with severe dementia and another with tracheostomy, gastrostomy, and ventilator dependence, were also transferred to hospitals without receiving the required written notices. Both residents had significant cognitive impairments and required substantial or total assistance with daily activities. The DON acknowledged that the facility's policies on bed-hold and transfer/discharge documentation were not followed for these residents, and that the lack of written notification resulted in the residents and their representatives not being informed of their rights.