Failure to Provide Written Transfer/Discharge and Bed-Hold Policy Notification
Penalty
Summary
A deficiency was identified when a resident with multiple medical conditions, including a left tibia and fibula fracture, respiratory failure with hypoxia, neuralgia, type 2 diabetes, anxiety disorder, epilepsy, and morbid obesity, was emergently transferred to the hospital after experiencing a seizure and becoming unresponsive. Although internal discharge paperwork was completed, there was no discharge documentation found in the resident's medical record. The facility's policy requires that notice of transfer or discharge, including the reason for transfer and bed-hold policy details, be provided to the resident and their representative in writing as soon as practicable, especially in emergency situations. Interviews with the DON and Administrator revealed that while some paperwork, such as a face sheet, resident orders, and a POLST form, was sent with the resident, no written notice of transfer or discharge or bed-hold policy was provided to the resident or their representative. The DON stated that the bed-hold policy was communicated verbally but not in writing, and the Administrator confirmed that a bed-hold agreement was not sent with residents transferred to the hospital. This failure to provide required written notifications and documentation at the time of transfer or discharge constituted the deficiency.