Failure to Provide Required Bed-Hold Notifications and Discharge Documentation
Penalty
Summary
The facility failed to provide required written notifications and documentation related to bed-hold policies and discharge procedures for two residents. For one resident with multiple diagnoses including hypertension, cirrhosis, liver carcinoma, and congestive heart failure, the facility did not provide a written notification of transfer or a bed-hold policy to the resident or their representative prior to several hospital transfers. The resident had severely impaired cognition and required staff assistance for daily activities, with documentation indicating an intention to remain in the facility for long-term care. Despite the facility's policy requiring a second written notice of bed-hold rights before each transfer or within 24 hours in emergencies, this was not completed as required. Additionally, another resident with osteoarthritis, Alzheimer's disease, and hypertension was admitted for a respite stay and subsequently discharged to another facility. The facility did not complete an admission MDS, Care Area Assessment, or a discharge summary that included a recapitulation of the stay. The discharge was described as sudden, and while the resident's spouse received medications and belongings, the required discharge summary and documentation were not completed as per facility policy. Staff interviews confirmed misunderstandings regarding the need for repeated bed-hold notifications and acknowledged the omission of the discharge summary due to the unexpected nature of the discharge. The facility's own policies specify the need for timely and comprehensive written notifications and summaries, which were not followed in these cases.