Failure to Provide Required Written Notification on Bed Hold and Transfer
Penalty
Summary
The facility failed to provide written notification to residents and their representatives regarding bed hold policies, transfer information, and Ombudsman contact details when residents were transferred to the hospital following a change in condition. Clinical record reviews for seven sampled residents who were transferred revealed no documentation that such notifications were given at the time of transfer. This lack of documentation was consistent across all reviewed cases, indicating a systemic issue in the facility's notification process. Additionally, staff interviews, including one with the Administrator, confirmed that there was no evidence to support that the required written notices were sent to the residents' representatives. The deficiency was identified through both clinical record review and staff interview, with all seven sampled residents affected by the same lapse in required communication during their transfer to the hospital.