Failure to Provide Required Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The facility failed to provide a written notice of transfer or discharge as soon as practicable and did not issue a bed-hold notice with the required information for a resident who experienced three facility-initiated transfers to the hospital. The resident, who had diagnoses of diabetes mellitus, congestive heart failure, and seizure disorder, was documented as having intact cognition and was dependent on staff for dressing and transfers. The resident's care plan and assessments consistently indicated a need for staff assistance with activities of daily living. Despite multiple hospital transfers, the facility did not send the required written notifications or bed-hold notices to the resident's legal representative. Interviews with administrative and social service staff confirmed that these notifications were not provided as required by facility policy. The facility's own policy stated that written notice specifying the duration of the bed-hold policy and information about the resident's return should be given at the time of transfer, but this was not followed for the resident in question.