Failure to Provide Required Discharge Notifications and Bed Hold Policy Documentation
Penalty
Summary
The facility failed to provide required written notifications and documentation related to resident discharges and transfers. Specifically, one resident was discharged against medical advice (AMA) to home, but the Ombudsman was not notified in writing of this unplanned discharge. The Director of Social Services confirmed that she only notified the Ombudsman of hospital transfers, not discharges to home, and the Administrator was unsure if home discharges required Ombudsman notification. Additionally, for three residents who were transferred to the hospital, there was no documentation that either the residents or their representatives received written notification of the reason for transfer/discharge or a copy of the bed hold policy. Nursing staff reported that they sent the required forms with the residents and placed copies in the medical records bin, but there was no evidence in the medical records that these notifications were provided. The Social Worker stated she no longer sent notifications to representatives and could not explain why this practice had stopped. The Business Office Manager indicated she discussed the bed hold policy with representatives but did not document these discussions in the residents’ electronic medical records. Interviews with various staff, including the DON, Social Worker, and Administrator, revealed inconsistencies in the process for providing and documenting required notifications and bed hold policy information. The Medical Records staff member, who was reportedly responsible for scanning these documents into the medical record, was unavailable for interview, and there was no documentation to confirm that the notifications were actually provided as required.