Failure to Provide Required Transfer, Bed-Hold, and Ombudsman Notifications
Penalty
Summary
The facility failed to provide required written documentation and notifications related to transfer, discharge, bed-hold policies, and Ombudsman notification for four residents out of a sample of twenty. Specifically, the facility did not issue written transfer and bed-hold notices to the appropriate resident representatives or notify the Office of the State Long-Term Care Ombudsman when residents were transferred to the hospital. This was confirmed through record review and staff interviews, which revealed the absence of documentation for these notifications in the clinical records of the affected residents. For one resident with a legal guardian, there was no evidence that the guardian received written notice of the hospital transfer or bed-hold policy, nor that the Ombudsman was notified. Another resident with a health care proxy also lacked documentation of written transfer and bed-hold notifications to the proxy and notification to the Ombudsman. In a third case, the record did not show that the Ombudsman was notified of the resident's hospital transfer. For a fourth resident, who was severely cognitively impaired, there was no evidence that transfer and bed-hold notifications were provided or that the Ombudsman was informed when the resident was sent to the hospital. Interviews with the social worker responsible for these notifications confirmed that the facility did not have a specific policy for bed-hold, transfer, and Ombudsman notification, and that federal regulations should have been followed. The social worker was unable to provide evidence that the required notifications were sent for any of the four residents involved in the deficiency.