Failure to Provide Required Transfer, Discharge, and Bed-Hold Notifications and Documentation
Penalty
Summary
The facility failed to provide required documentation and notifications related to resident transfers, discharges, and bed-hold policies for multiple residents. Specifically, there was no evidence that the Long-Term Care Ombudsman was notified of several residents' transfers to the hospital or discharges, as required by facility policy and regulations. For example, one resident with significant medical needs, including paraplegia and dementia, was hospitalized multiple times, but the facility could not provide documentation of ombudsman notification for these events. Additionally, bed-hold notices were only available for some hospitalizations, not all, and written discharge notices were not consistently provided to residents or their representatives prior to transfer or discharge. Another resident with intellectual disabilities and behavioral issues was transferred to the hospital, but the facility failed to document the transfer in the medical record as required. The policy mandates that the date, time, and personnel involved in the discharge be recorded, but this information was missing. In another case, a resident left the facility against medical advice, and the facility did not notify the ombudsman of the discharge, contrary to policy. Similarly, for a resident discharged after exhausting bed-hold days, the facility could not provide documentation that the required notice was sent to the ombudsman. These deficiencies affected all residents reviewed for transfer and discharge requirements. The facility's failure to provide proper documentation and notifications, including ombudsman notification and bed-hold notices, was confirmed through interviews with facility leadership and review of medical records and facility policies. The lack of required documentation and notification was observed in each case, with staff confirming the absence of these records during interviews.