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F0628
B

Failure to Provide Required Written Notifications and Bed Hold Documentation During Hospital Transfers

Elizabeth City, North Carolina Survey Completed on 05-21-2025

Penalty

Fine: $16,720
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide required written notifications and documentation related to resident transfers and discharges to the hospital. For three residents reviewed, there was no evidence that written transfer or discharge notices were given to the residents or their representatives at the time of hospitalization. In each case, the medical records lacked documentation of these notices, and interviews with staff confirmed that written notifications were not provided, although phone calls were sometimes made to inform resident representatives. Additionally, the facility did not properly complete the bed hold policy documentation. For one resident, the bed hold form was signed by the resident representative, but critical sections such as the dates of hospitalization and the acceptance or declination of the bed hold were left incomplete. The business office manager indicated that her involvement with the bed hold policy was limited to payment discussions if the resident or representative expressed interest, and that nursing staff sent the form with the resident by default. There was confusion among staff regarding responsibility for follow-up and completion of the bed hold process. The facility also failed to notify the Ombudsman in writing of resident transfers or discharges to the hospital. The social worker acknowledged that the required transfer/discharge list had not been sent to the Ombudsman for the relevant month, citing being behind on this task. Staff interviews revealed a lack of awareness regarding the requirement to send written notices to residents, representatives, and the Ombudsman, contributing to the deficiency.

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