Failure to Provide Bed-Hold and Ombudsman Notifications During Resident Transfers
Penalty
Summary
The facility failed to provide required bed-hold notifications to two residents and their representatives during hospital transfers, as well as ombudsman notifications for one resident. For one resident with diagnoses including extended spectrum beta lactamase infection, CHF, chronic kidney disease, and major depressive disorder, the electronic health record did not contain documentation of a bed-hold notification when the resident was transferred to the hospital for evaluation and treatment of respiratory and urinary symptoms. The administrative nurse confirmed that there was no evidence of a signed or verbally acknowledged bed-hold policy notice provided to the resident or their representative at the time of transfer. Another resident, who had a history of hemiplegia, hemiparesis, stroke, pain, and respiratory failure, experienced multiple discharges and returns to the facility. The progress notes indicated that the resident's durable power of attorney requested a bed-hold, but the facility did not provide a written bed-hold signature from the representative. Additionally, the facility was unable to provide an ombudsman notification policy for discharges and transfers, and social services staff confirmed that neither bed-hold notifications nor ombudsman notifications were sent for the resident's discharges. The facility's own policy, dated January 2024, requires that written notice specifying the duration of the bed-hold be provided to residents or their representatives at the time of transfer for hospitalization or therapeutic leave. Despite this policy, documentation and staff interviews revealed that these notifications were not provided as required, resulting in a deficiency related to resident rights and required notifications during transfers.