Failure to Provide Required Transfer Notifications and Bed-Hold Notices
Penalty
Summary
The facility failed to provide required written notifications and documentation related to resident transfers to the hospital for three residents. Specifically, there was no documented evidence that written notification of transfer was provided to the residents or their representatives, no evidence that a bed-hold notice was given to the responsible parties, and no evidence that the ombudsman was notified of the transfers, as required by facility policy and regulation. These deficiencies were identified through review of policies, clinical records, and staff interviews. The residents involved had significant medical needs at the time of transfer. One resident, who was cognitively intact and required assistance for all daily care needs, was transferred due to involuntary jerking movements, lethargy, and increased leg swelling. Another resident, also cognitively intact and requiring minimal assistance, was transferred after a fall resulting in a forehead bruise and subsequent hospital admission for anemia, hematoma, gastrointestinal bleed, and diverticulosis. The third resident, who was cognitively impaired and required maximum assistance, was transferred due to coughing up blood and rectal bleeding. In each case, the required notifications and documentation were not completed.