Failure to Provide Timely Bed Hold Notice and Written Transfer Notification
Penalty
Summary
Facility staff failed to implement required hospital transfer procedures for two residents. For one resident, staff did not provide a written bed hold notice when the resident was transferred to the hospital for evaluation of right jaw swelling, despite facility policy requiring that a bed hold notice be given to the resident or their representative at the time of transfer. Review of the clinical record did not show documentation that the notice was provided, and staff interviews confirmed that the process was not followed as required. For another resident, the facility did not provide timely written notification to the responsible party regarding two facility-initiated hospital transfers for abdominal pain. Although certified mail receipts showed that written notifications were eventually sent, they were mailed 17 and 7 days after the respective transfers, rather than within a practicable timeframe. Staff interviews confirmed that the notifications were not sent promptly, and the responsible party was not informed in writing within the expected period following the transfers.