Failure to Provide Bed Hold Notifications and Discharge Documentation
Penalty
Summary
The facility failed to provide required written bed hold notifications to two residents at the time of their transfer to the hospital, as well as failed to document a physician's order for discharge for one resident. For one resident with multiple diagnoses including type 2 diabetes, end stage renal disease, hemiplegia, major depressive disorder, and PTSD, there was no evidence in the record that a bed hold notification was given when the resident was transferred to the hospital. The resident reported not receiving this notification and was informed by the hospital about the risk of losing their LTC bed after three days. Staff interviews confirmed the absence of the required documentation, and the facility was unable to produce the bed hold notice upon request. Additionally, the State Ombudsman was not informed of the resident's discharge to the hospital, as the facility only reported incidents or discharge concerns to the Ombudsman. For another resident with diagnoses including a wedge compression fracture, type 2 diabetes, and nonalcoholic steatohepatitis, the medical record review showed that the resident was transferred and subsequently discharged, but there was no physician's order documenting the discharge. Progress notes indicated that the provider was notified and agreed to send the resident to the ER due to altered mental status, but the required discharge order was not found in the record. The Medical Records Supervisor and DON both confirmed the absence of the physician's discharge order and bed hold notice in the resident's file. Facility policy requires that residents or their representatives be informed in writing of their right to a bed hold both upon admission and prior to transfer, with a provision for notification within 24 hours in emergencies. The review of a blank bed hold notification form confirmed that Medicaid beneficiaries are responsible for bed hold costs and must notify the facility within 24 hours if they wish to exercise this option. Despite these policies, the facility did not provide the required notifications or documentation for the residents in question, resulting in incomplete records and a lack of proper communication regarding bed hold rights.