Failure to Notify Ombudsman and Provide Bed Hold Notices During Resident Hospitalizations
Penalty
Summary
The facility failed to provide required notifications and documentation related to resident transfers and discharges, specifically omitting notification to the Ombudsman for several residents who were hospitalized. For example, one resident with diagnoses including ataxia, COPD, chronic back pain, and paranoid schizophrenia was transferred to an acute care hospital after calling 911 due to back pain. The medical record and staff interview confirmed that the Ombudsman was not notified of this transfer. Similar failures to notify the Ombudsman were identified for three other residents who experienced hospitalizations, as evidenced by the absence of these residents on monthly discharge notices and lack of documentation in their records. Additionally, the facility did not ensure that residents or their legal representatives were informed of bed hold rights or provided with written notices of transfer in at least one case. For a resident dependent on staff for transfers and with multiple complex medical conditions, there was no documentation that a bed hold notice was given during a hospital transfer, and the facility confirmed that no bed hold was provided. These deficiencies were identified through review of medical records, facility documentation, and staff interviews, which consistently showed a lack of required notifications and documentation for residents transferred to hospitals.