Failure to Notify Ombudsman, Provide Bed Hold Policy, and Discharge Instructions
Penalty
Summary
Surveyors identified that the facility failed to notify the Ombudsman of resident transfers and did not provide written notice of the facility's bed hold policy to residents or their representatives upon transfer to the hospital. Specifically, for two residents who were hospitalized, there was no documentation that the Ombudsman was informed of their transfers, and no evidence that the bed hold policy was communicated in writing to their responsible parties. Interviews with the Regional Clinical Director confirmed that, during the relevant period, the facility was not providing these required notifications or documentation. Additionally, the facility failed to provide discharge instructions to a resident and their family upon discharge after rehabilitation for deconditioning and medication management following a kidney transplant. The resident had complex care needs, including gastrostomy tube feeding, wound care, and anti-rejection medications, yet there was no documentation of discharge planning or instructions provided at the time of discharge. The absence of this documentation was confirmed by the Regional Clinical Director during the survey.