Failure to Document Provision of Bed Hold Policy and Transfer/Discharge Notifications
Penalty
Summary
The facility failed to provide proper documentation and notification regarding bed hold policies and transfer/discharge notifications to residents and/or their representatives during hospitalizations. For three residents with varying cognitive statuses and medical conditions such as respiratory failure, COPD, hypertension, dementia, and post-stroke deficits, the clinical records showed that while the required forms and bed hold policies were attached, there was no documentation indicating to whom these documents were provided. In each case, the records lacked evidence that the resident or their representative received the necessary notifications at the time of transfer or discharge to the hospital, as required by facility policy. Additionally, for one resident discharged to another long-term care facility, the clinical record did not contain documentation that the resident's discharge information was communicated to the receiving provider. Although the resident's daughter was given a packet of information and medications, there was no record of the receiving facility being provided with the required transfer information, such as the basis for transfer, practitioner contact, care plan, and other essential details for continuity of care. Interviews with facility staff confirmed that while procedures were in place to print and distribute documentation, there was no evidence in the clinical records to verify that the required notifications and information were actually provided to the appropriate parties. Facility policies reviewed specified the need for written notification and documentation of attempts to notify representatives, as well as the communication of comprehensive transfer information to receiving providers, but these requirements were not met in the reviewed cases.