Failure to Provide Timely Bed Hold Notice, Ombudsman Notification, and Discharge Planning
Penalty
Summary
The facility failed to complete required documentation and notifications related to transfer/discharge and discharge planning for two residents. For one resident with diabetes mellitus and major depressive disorder, the facility did not provide a written bed hold notice at the time of transfer to a general acute care hospital, instead relying on a previously signed form from admission and only obtaining a new signature upon the resident's return. Additionally, the Notice of Proposed Transfer and Discharge was not provided to the Ombudsman at the time of transfer, but rather two days later. Interviews with facility staff, including the Administrator, Social Services Director, and Director of Nursing, confirmed that the bed hold notice and Ombudsman notification should have been completed at the time of transfer, in accordance with facility policy. Record review and staff interviews further revealed that the Social Services Director did not assist another resident, who had anxiety, bipolar disorder, and congenital deformities, with discharge planning after the resident requested to move to an assisted living facility. The resident, who was cognitively intact and required some assistance with activities of daily living, reported that she had informed the Social Services Director of her desire to leave the facility weeks prior, but had not received any assistance or updates. The Social Services Director acknowledged responsibility for helping with placement and admitted to not starting the process, despite the resident being medically stable and safe for discharge. Facility policies reviewed indicated that written bed hold information must be provided prior to transfer, and that the Notice of Proposed Transfer and Discharge should be given to the Ombudsman at the time of transfer. The policies also require timely and accurate documentation to support resident care and legal compliance. The failure to follow these procedures resulted in incomplete documentation and lack of support for residents' rights and discharge planning.