Failure to Communicate Resident Information and Bed-Hold Policy During Transfers
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider during facility-initiated transfers for two residents. Specifically, for both residents, there was no documented evidence that information such as care plan goals, advanced directive details, specific instructions for ongoing care, resident representative information, and all other information necessary to meet the residents' needs was provided to the hospital at the time of transfer. This lack of communication was confirmed through clinical record review and staff interviews. Additionally, the facility did not provide written notification of the bed-hold policy to the residents or their representatives at the time of hospital transfer, as required by facility policy. Both residents were transferred to the hospital and later returned, but their records did not contain documentation that the bed-hold policy was communicated. Staff interviews further confirmed that this notification was not provided.