Failure to Provide Required Transfer Documentation and Bed Hold Policy
Penalty
Summary
The facility failed to provide the required documentation and notifications related to hospital transfers for a resident with multiple complex medical conditions, including end stage kidney disease, heart failure, and emphysema. On several occasions, the resident was transferred to the hospital, but the documentation did not consistently indicate that the resident's family or representative had been notified. In some instances, event reports noted that a representative was notified, but did not include the representative's name or contact information. Progress notes often lacked documentation of family notification at the time of transfer. Additionally, the facility did not attach a copy of the bed hold policy to the Notice of Transfer or Discharge forms as required. Although the bed hold policy was included in the admission agreement, it was not provided with the transfer documentation for any of the hospital transfers reviewed. Facility policy required that the bed hold policy be reviewed with the responsible party and documented in the medical record, but this was not done. Interviews with staff confirmed that the required notifications and documentation were not consistently completed.