Failure to Provide Required Transfer Notifications, Bed Hold Policies, and Communication During Resident Transfers
Penalty
Summary
Facility staff failed to provide required written transfer notifications, bed hold policies, and call reports to the receiving hospital for multiple residents who were transferred to acute care hospitals. For several residents, there was no documentation that written transfer notices were given to the residents or their representatives at the time of transfer, nor were copies of these notices found in the residents' records. In some cases, residents or their representatives reported not receiving timely notification or explanation regarding the transfer, and staff interviews confirmed that these notifications were not provided as required. Additionally, the facility did not consistently offer or document bed hold policies to residents or their representatives during hospital transfers. In instances where residents declined bed holds, the forms lacked a witness staff signature to verify verbal consent. The facility also failed to document that staff called and reported the residents' medical status to the receiving hospital at the time of transfer for several residents, as expected for continuity of care. The report further notes that the Office of the State Long Term Care Ombudsman (LTCO) was not notified for certain resident transfers, and in one case, the resident's medical provider was not notified of a discharge. Staff interviews confirmed these omissions, and staff acknowledged the importance of these notifications and documentation for resident safety and informed decision-making. The deficiencies were identified through record reviews and staff and resident representative interviews.