Failure to Provide Written Bed-Hold and Transfer Notices Upon Hospitalization
Penalty
Summary
The facility failed to provide required written notifications to residents and their representatives regarding bed-hold policies, transfer information, and Ombudsman contact details when residents were transferred to the hospital. Specifically, for five out of six sampled residents who experienced a change in condition and were subsequently transferred and admitted to the hospital, there was no documentation that written information about the bed-hold policy or the reasons for transfer was given to the residents or their representatives. Clinical record reviews for these residents showed multiple instances of hospital transfers following changes in condition, yet in each case, the necessary written notifications were not documented. An interview with the Administrator confirmed that there was no evidence to support that these notices were sent to the appropriate parties at the time of transfer.