Failure to Provide Written Transfer and Bed-Hold Notifications
Penalty
Summary
The facility failed to provide written notification to residents and their representatives regarding the reason for transfer to the hospital, as well as to issue required bed-hold notices to the responsible parties for two residents. According to the facility's policy, residents and/or their representatives must receive written information about bed-hold policies both in advance (such as at admission) and at the time of transfer, or within 24 hours if the transfer is emergent. For one resident with moderate cognitive impairment and dementia, who was transferred to the hospital for pneumonia, there was no documented evidence that either the transfer notification or the bed-hold notice was provided to the resident or their representative. Similarly, another resident, who was cognitively intact and had diagnoses including heart failure, hypertension, and kidney failure, was transferred to the hospital after experiencing shortness of breath and fatigue. There was no documentation that written notification of the transfer or a bed-hold notice was provided to this resident or their responsible party. Interviews with the Nursing Home Administrator confirmed that these notifications were not given as required by facility policy and state regulations.