Failure to Provide Written Transfer and Bed Hold Notices During Emergent Hospital Transfers
Penalty
Summary
The facility failed to provide written bed hold policies and transfer notices to residents or their representatives during emergent hospital transfers, as required by both facility policy and federal regulations. This deficiency was identified through resident and staff interviews, record reviews, and examination of the facility's policy on involuntary transfers and discharges. The policy specifies that, for emergency transfers or discharges, documentation must be made in the medical record, and a Notice of Involuntary Transfer and Discharge form must be provided to the resident, their representative, and the resident's physician as soon as practicable, with a copy kept in the medical record. Seven residents who experienced emergent transfers to the hospital were reviewed, and in each case, there was no evidence that a written notice of transfer or bed hold policy was provided to the resident or their representative. The medical records for these residents documented various acute events, such as falls resulting in injury, unresponsiveness, and respiratory distress, which led to their transfer to the hospital. Despite these events, the required written notifications were not found in the records, and in some cases, residents and their representatives confirmed they did not receive any written information regarding the transfer, its reasons, or their appeal rights. Interviews with facility staff, including an LPN, the Administrator, the Social Worker, and the Interim Director of Health Services, revealed a lack of awareness and practice regarding the provision of written transfer and discharge notices. Staff members stated they had never filled out such notices for hospital transfers and were unaware of the requirement until it was brought to their attention during the survey. The facility only had forms for 30-day discharges, which were not used for emergent hospital transfers.