Failure to Provide Bed Hold and Ombudsman Notifications During Resident Discharge and Transfer
Penalty
Summary
The facility failed to provide required Bed Hold Notifications to two residents at the time of their emergency transfers to the hospital. In both cases, the residents had significant medical histories, including heart failure, osteoarthritis, pain, Parkinson’s disease, diabetes, depression, and repeated falls. Documentation showed that neither the residents nor their representatives received information about the facility’s bed-hold policy at the time of transfer, as required by the facility’s own policy and federal regulations. Administrative staff confirmed that the notifications were not provided during interviews. Additionally, the facility did not notify the Office of the Long-Term Care Ombudsman (LTCO) of the discharges for three residents. Review of records and staff interviews revealed that the last notification to the ombudsman had been made several months prior, and there was no evidence that the ombudsman was informed of the recent discharges. This was despite the facility’s policy stating that such notifications should be made, either at the time of transfer or via a monthly list. The documentation and interviews indicated that the facility’s processes for both bed-hold notification and ombudsman notification were not followed for the residents involved. The lack of timely and appropriate notifications was confirmed by administrative staff and was not in accordance with the facility’s written policies.