Failure to Provide Required Written Notification for Resident Transfer and Bed Hold
Penalty
Summary
The facility failed to provide written notification to a resident and the resident's representative regarding a transfer to the hospital, including the reasons for the move, in a language and manner they understood. The required notice was also missing key information such as the reason, date, and location of the transfer, as well as a statement of the resident's appeal rights and contact information for the state Long-Term Care Ombudsman. Instead, the facility relied on verbal communication with the resident's representative and did not send written documentation as required by policy and regulation. The resident involved had a history of type II diabetes mellitus with hyperglycemia, hyperlipidemia, mild cognitive impairment, and hypertension. She was hospitalized for abdominal pain and sepsis due to kidney stones and later returned to the facility. Interviews with facility staff, including the ADON, DON, SSD, and Administrator, confirmed that written notifications were not provided to the resident's representative or the Ombudsman, and that the facility's practice was to discuss bed hold policies only at admission, not at the time of transfer or discharge.