Failure to Provide Required Written Discharge, Transfer, and Bed Hold Notifications
Penalty
Summary
The facility failed to provide the required written discharge or transfer information to residents and their representatives for multiple residents who were hospitalized or discharged. Specifically, there was no written notification of discharge or transfer provided in a language and manner understandable to the resident or their representative, and in some cases, no documentation of the discharge or transfer was present in the medical record. For one resident, there was no discharge summary that included a recapitulation of the stay, final clinical status, or medication reconciliation. Additionally, written notices did not include required information about appeal rights or contact information for the State Long-Term Care Ombudsman. For several residents who were transferred to the hospital, the facility did not provide written transfer notifications or bed hold notifications at the time of transfer or as soon as practicable. In some cases, the bed hold notification was completed but did not indicate who was notified, and there was no evidence that a written copy was given to the resident or their representative. Staff interviews confirmed that written notifications were not consistently provided, and that the process for notifying residents, representatives, and the Ombudsman was not followed as required. The facility also failed to send copies of the written discharge or transfer notices to the Ombudsman, instead only sending a list of residents who transferred or were discharged. Staff responsible for these notifications, including the Social Services Director and Business Office Manager, confirmed that written notifications were not always provided or documented, and that family members were sometimes only notified by phone or required to pick up written notices in person. These deficiencies were identified through record review and staff and resident interviews.