Failure to Provide Bed Hold and Ombudsman Notification at Discharge
Penalty
Summary
The facility failed to provide a Bed Hold Notification and notification to the State Ombudsman Agency regarding the discharge of a resident with multiple complex medical conditions, including hemiplegia, hemiparesis following a stroke, chronic kidney disease, diabetes mellitus, obesity, nicotine dependence, lymphedema, polyarthritis, COPD, and chronic respiratory failure with hypoxia. The resident required significant assistance with activities of daily living, used a wheelchair for mobility, and was frequently incontinent of urine. The resident's medical record documented several discharges and entries, but lacked evidence of a Bed Hold Notification for one of the discharges, as required by facility policy. Social Services staff confirmed responsibility for providing discharged residents with the facility's bed hold policy and notifying the State Ombudsman Agency, but acknowledged that this was not done for the resident in question during certain hospitalizations. The facility's written policy required that a notice specifying the duration of the bed-hold policy be issued to the resident or their representative upon transfer to a hospital or therapeutic leave, but this was not consistently followed in this case.