Failure to Provide Bed-Hold Policy Notification and Ombudsman Notification During Resident Transfers
Penalty
Summary
The facility failed to provide required written notification of its bed-hold and return policy to residents who were transferred to the hospital, and did not notify the Ombudsman advocate of these transfers. Specifically, for two residents with significant medical histories—one with blood clots and kidney and bladder cancer, and another with a history of stroke and left-side paralysis—there was no documentation in their medical records that they received written notice regarding the facility's bed-hold policy at the time of their hospital transfers. Additionally, there was no evidence that the Ombudsman was informed of their transfers, which is necessary to ensure advocacy for residents during their absence from the facility. Staff interviews confirmed that the Director of Nursing acknowledged the lack of bed-hold policy notification, stating that residents are only informed upon admission that the facility does not hold beds for discharged residents. The CCU Coordinator also stated that the Ombudsman is only contacted if assistance is needed, not routinely notified of transfers or discharges. These actions and omissions were identified through record review and staff interviews, and were found to be true for two of four residents reviewed for discharge documentation.