Failure to Provide Required Transfer/Discharge and Bed Hold Notices
Penalty
Summary
The facility failed to provide required written documentation related to transfer/discharge notices and bed hold policies for three residents who experienced hospitalizations. For one resident with paraplegia and communicating hydrocephalus, who was cognitively intact and fully dependent on staff for daily activities, the clinical record showed multiple hospital transfers without any indication that transfer or bed hold notices were provided. Similarly, another cognitively intact resident with osteomyelitis and blindness was transferred to the hospital, but the clinical record did not show that the required notices were given. A third resident, who had severe cognitive impairment and could not participate in mental status interviews, was hospitalized three times, yet there was no documentation that transfer/discharge notices were provided to the resident or their representative. In interviews, the Social Worker confirmed that these notices were not completed and stated that the process does not occur in her absence.