Failure to Provide Required Bed-Hold and Transfer Notifications
Penalty
Summary
The facility failed to provide required written documentation and notifications related to bed-hold policies and transfer notices for multiple residents who were transferred to the hospital. In several instances, residents were sent out to the emergency department due to acute changes in condition, such as confusion, altered mental status, and suspected appendicitis. Despite these transfers, there was no evidence in the medical records that the residents or their representatives received written information about the facility's bed-hold policy or written notification of the transfer. Additionally, there was no documentation that the Office of the State Long-Term Care Ombudsman was notified of the transfers as required. Specifically, staff interviews and record reviews confirmed that written bed-hold policies and transfer notifications were not provided at the time of transfer for the residents involved. Facility policy requires that residents and their representatives be informed in writing of bed-hold and return policies prior to transfer, and that the ombudsman be notified of such events. However, documentation and staff statements revealed these steps were not completed, with staff citing workload and busy conditions as reasons for the omissions.