Failure to Communicate Resident Information and Provide Bed-Hold Policy Notification During Transfers
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to receiving health care providers during facility-initiated transfers for four out of six sampled residents. Specifically, the clinical records for these residents did not contain documentation that key information such as care plan goals, advance directive information, special instructions for ongoing care, resident representative contact information, and all other details necessary to meet the residents' needs were provided to the receiving providers. This lack of communication was confirmed through both clinical record review and staff interviews, including with the DON and Nursing Home Administrator. Additionally, the facility did not provide written notification of its bed-hold policy to residents or their representatives for three out of six hospital transfers. The bed-hold policy requires that residents or their representatives receive written notice within 24 hours of an emergency transfer, outlining the facility's agreement to hold a bed for an agreed-upon rate during hospitalization. Clinical record reviews for the affected residents showed no evidence that this required notification was given at the time of transfer. The residents involved had various medical conditions, including muscle wasting, anemia, dementia, reduced mobility, and dependence on supplemental oxygen. The deficiencies were identified through a combination of policy review, clinical record examination, and staff interviews, which confirmed the absence of required documentation and communication at the time of transfer and hospitalization.