Failure to Provide Written Transfer and Bed Hold Notices During Hospital Transfers
Penalty
Summary
Facility staff failed to provide required written notices of transfer and bed hold policies to residents and/or their representatives during hospital transfers for two residents. In the first instance, a resident was transferred to the emergency room due to medication refusal, aggressive behaviors, and psychosis. Although forms documenting the resident's and responsible party's names and the date were completed, there was no evidence that these notices were actually provided to the resident or their representative. The director of social services stated that notices are typically mailed and kept in her office, but could not provide proof that the notices were sent or received in this case. In the second instance, another resident was transferred to the hospital after exhibiting a high temperature and low blood pressure, with the transfer initiated at the request of the resident's spouse. The clinical record did not contain documentation that the required written notice and bed hold policy were sent to the responsible party. The social worker confirmed that while copies of the notices existed, there was no evidence they were actually sent. Facility policy requires notification of bed hold policies at admission and at the time of transfer, but documentation supporting compliance was not available for these two cases.