Failure to Provide Written Transfer and Bed-Hold Notices During Hospitalization
Penalty
Summary
The facility failed to provide required written notices of transfer and bed-hold policies to residents and/or their representatives at the time of transfer for three residents who were hospitalized. For one resident, documentation showed a change in condition that led to a 911 call and subsequent hospital admission for a urinary tract infection. The resident returned to the facility several days later, but there was no documentation that the resident or their representative received written notice of the transfer or the facility's bed-hold policy. This lack of documentation was confirmed by the Director of Nursing during an interview. Another resident was transferred to the emergency room for evaluation due to mental status changes, weakness, and frequent falls, and was admitted to the hospital for weakness and pneumonia. Again, there was no documentation that the resident or their representative received the required written notices at the time of transfer. The surveyor requested this documentation during meetings with facility leadership, but it was not provided. A third resident was transferred to the hospital for a change in condition and returned after a short stay. Review of the clinical record revealed no documentation that the resident's representative received written notice of transfer or the facility's bed-hold policy. Interviews with facility staff confirmed that these notices were not provided as required. The deficiency was identified through clinical record review and staff interviews, which consistently showed a lack of compliance with federal requirements for written notification during resident transfers.
Plan Of Correction
The facility provides a written Bed Hold Acknowledgment and Notice of Transfer document containing all the required elements, including the date of transfer, specific reason for discharge/transfer, location to be transferred, right to appeal process information, and the information pertaining to the Office of the Long-Term Care Ombudsman to the responsible party for those residents identified (#28, 59, and 65). A copy of the Bed Hold Acknowledgment and the Notice of Transfer Document was sent to residents #28, #59, and #65. Once a copy of the signed documents is returned, they will be filed in the resident's medical chart. A review of the facility's resident records, who were transferred over the past six (6) months, will be completed, and corrective actions will be taken if necessary. Education was provided by Social Services and the Admissions Director on the Notice Requirements before Transfer/Discharge Notification Program and the process to be completed upon each transfer. Education was provided to all Nursing Staff. Any future transfers will be reviewed by the Admission Director at the morning meeting (five days per week) to ensure proper procedures were followed for the Notice Requirements before Transfer/Discharge process, including the initial notification verification, and the written notification of the transfer/discharge and the reasons for the move. Audits will be completed on all transfers weekly for two months and bi-weekly for three months. Findings will be presented to the Quality Assurance Performance Improvement committee for recommendations, including an explanation of any identified variance infractions.