Failure to Provide Written Notification of Transfer and Bed-Hold Policy
Penalty
Summary
The facility failed to provide written notification to a resident's representative regarding the resident's transfer to the hospital and the facility's bed-hold policy. The resident, who had a history of hypertension, type 2 diabetes mellitus with chronic kidney disease, and hyperlipidemia, was admitted to the facility and later hospitalized for vomiting blood, where she was diagnosed with a pyloric obstruction and a urinary tract infection. Upon her return from the hospital, documentation showed that the facility's Transfer/Discharge and Bed Hold Policy Notification form was not signed by the resident or her representative; instead, it was noted that verbal consent was obtained via a phone call. The resident's representative confirmed that she was verbally informed of the transfer but did not receive any written documentation regarding the bed hold or the transfer. Interviews with facility staff, including the Business Office Manager, Social Services Director, Admission Coordinator, Assistant Director of Health Services, Director of Health Services, and Executive Director, revealed that the facility's practice was to notify the resident's representative of transfers and the bed hold policy by phone, but not to provide written notification by mail. Staff indicated that a copy of the notification was sent with the resident to the hospital and that the Ombudsman was notified via email and monthly reports. However, there was no evidence that written notification was provided directly to the resident's representative as required.