Failure to Provide Required Bed Hold and Transfer/Discharge Notices During Hospital Transfers
Penalty
Summary
The facility failed to provide required documentation and notification regarding bed hold and transfer/discharge rights to three residents who were transferred to the hospital. For one resident with metabolic encephalopathy, Parkinson’s disease, and clostridium difficile, there was no documentation in the progress notes that a bed hold or notice of transfer/discharge was provided when the resident was sent to the hospital. Staff interviews confirmed that the transfer packet did not include the necessary documentation and staff were unaware of any facility document related to these notices. Another resident with COPD, chronic heart failure, and a pelvis fracture was transferred to the hospital after a fall, but there was no documentation of a bed hold or transfer/discharge notice. Staff confirmed the absence of these documents. A third resident with a history of falls and a fracture was also transferred to the hospital, and although a checkbox indicated that bed hold/transfer notices were sent, there were no copies or follow-up documentation to confirm that the resident or their representative was informed. Staff interviews revealed that while the form is supposed to be sent with the resident, no copies are kept, and there was no documentation in the medical record to verify that the required notifications were provided.