Failure to Provide Bed Hold Notices and Ombudsman Notification During Hospital Transfers
Penalty
Summary
The facility failed to provide written bed hold notifications to two residents who were transferred to the hospital. In one case, a cognitively intact resident with multiple diagnoses, including hemiplegia, COPD, depression, and a history of prostate cancer, was transferred to the emergency department due to a decline in condition. Documentation showed that the resident and family were informed of the transfer, but there was no evidence in the progress notes or electronic medical record that a bed hold notice was discussed or provided at the time of transfer or during hospitalization. The administrator confirmed that the notification process was missed due to personnel changes. In the second case, another cognitively intact resident with several chronic conditions was sent to the emergency room, but staff interviews revealed that no bed hold notice was provided or discussed, and there was confusion among staff regarding when bed hold notifications should be issued. Additionally, the facility failed to notify the Ombudsman of resident transfers to the hospital as required. The social worker reported only recently becoming aware of the requirement to send monthly notifications to the Ombudsman and had not done so prior to the last month. The facility's bed hold policy stated that all residents must receive a bed hold notice and a copy of the policy prior to or at the time of departure for either planned or emergency absences, but this was not followed in the cases reviewed.