Failure to Provide Required Transfer and Bed-Hold Notices
Penalty
Summary
The facility failed to provide required written notifications to residents or their representatives regarding transfers to the hospital, including the reason for transfer or discharge, date and location of transfer, statement of appeal rights, and contact information for the State Long Term Care Ombudsman. Additionally, the facility did not provide written notice of the bed-hold policy at the time of transfer for all residents reviewed who were hospitalized. This was confirmed through facility policy review, clinical record review, and staff interviews, which revealed that nursing staff were not completing or sending the necessary notices as required by facility policy. Specific examples included residents with diagnoses such as wedge compression fracture, hypertension, anxiety disorder, congestive heart failure, and acute respiratory failure, who were transferred to the hospital without the appropriate documentation being provided. In some cases, there was no evidence in the clinical record that the bed-hold policy or transfer notice was reviewed or given to the resident or their representative. Interviews with the DON confirmed that staff were unaware of the requirement to complete these notices, resulting in the deficiency.