Failure to Provide Bed Hold Policy and Transfer/Discharge Notifications During Hospital Transfers
Penalty
Summary
The facility failed to provide required bed hold policy and transfer/discharge notifications to residents or their representatives during hospital transfers for two residents. In the first case, a resident with diagnoses including acute on chronic diastolic heart failure and hypertension, who was cognitively intact, was transferred to the emergency room after complaining of worsening pain. The clinical record did not indicate that a transfer/discharge form or bed hold policy was provided to the resident or their representative at the time of transfer. In the second case, a resident with primary hemiplegia, hemiparesis following a cerebral infarction, hypertension, and oropharyngeal dysphagia, who was severely cognitively impaired, was sent to the emergency room after a fall resulting in a forehead laceration. The clinical record similarly lacked documentation that the required transfer/discharge form and bed hold policy were provided to the resident or their representative. Interviews with nursing staff and the DON confirmed that these notifications and documentation were not completed as required by facility policy.