Failure to Document Bed Hold Policy and Notify Ombudsman After Resident Transfers and Discharges
Penalty
Summary
The facility failed to provide required documentation and notifications related to bed hold policies and ombudsman notification for three residents who were hospitalized or discharged. For one resident with cognitive communication deficit and muscle weakness, there was no documentation that bed hold information was provided at the time of transfer to the hospital following an acute episode. Similarly, another resident with respiratory failure and hemiplegia was transferred to the hospital without documentation of bed hold information being given, and a completed transfer form was not found in the record. Additionally, a resident with chronic respiratory failure and end stage renal disease was discharged and later returned, but the ombudsman was not notified of the discharge as required, and there was no documentation that the bed hold policy was provided during a subsequent hospital transfer. Interviews with staff confirmed that while transfer forms and bed hold policies were reportedly sent with residents, there was no documentation in the electronic health record to verify this, and the ombudsman notification list did not include the resident in question. Facility policies require written information on bed hold practices to be provided and documented, and for the ombudsman to be notified of transfers and discharges, but these procedures were not followed for the residents reviewed.