Failure to Notify Ombudsman and Provide Bed-Hold Policy at Transfer/Discharge
Penalty
Summary
The facility failed to notify a representative of the Office of the State Long-Term Care Ombudsman regarding the transfer or discharge of four residents. Additionally, the facility did not provide written information about the bed-hold policy to three residents or their representatives at the time of transfer, or within 24 hours in cases of emergency transfer. These deficiencies were identified through clinical record reviews and staff interviews, which revealed a lack of documentation for both the required notifications and the provision of bed-hold policy information. Specific instances included residents being transferred to hospitals for various medical reasons, such as scheduled surgical procedures, urinary tract infection, encephalopathy, and sepsis, without evidence that the bed-hold policy was communicated or that the Ombudsman was notified. In one case, a resident was discharged to home without medication reconciliation being completed prior to discharge. Interviews with the Director of Nursing and the Nursing Home Administrator confirmed the absence of required documentation and notifications for these events.