Failure to Provide Required Transfer/Discharge and Bed Hold Notices
Penalty
Summary
The facility failed to provide required written documentation regarding transfer/discharge notices and bed hold policies for three residents who were transferred to the hospital. According to the facility’s policy, residents and their representatives must receive written notice of transfer or discharge, including the reason, effective date, location, appeal rights, and bed hold policies, either prior to or as soon as practicable before the transfer. In each of the three cases reviewed, the medical records did not contain evidence that these notices were completed or provided. Staff interviews confirmed that the required documentation was not done for these residents at the time of their hospital transfers. The residents involved had significant medical conditions, including acute and chronic respiratory failure, COPD, diabetes, cirrhosis, atrial fibrillation, chronic kidney disease, falls, and hyponatremia. Despite multiple hospital transfers for changes in condition, there was no documentation of bed hold or transfer/discharge notices in the records for these events. Staff members, including nurses, social workers, and managers, acknowledged during interviews that the notices were not completed as required by policy.