Failure to Provide Required Transfer Notices, Bed Hold Policies, and Discharge Planning Documentation
Penalty
Summary
The facility failed to provide required written notices and documentation to residents at the time of transfer or discharge, as well as to offer bed hold policies and notify the Long Term Care Ombudsman (LTCO) as required. In several instances, residents were transferred to hospitals without receiving signed transfer or discharge notices. For example, one resident was discharged to the hospital, but the transfer notice was not signed by either the administrator or the resident/representative, and staff could not locate a signed form. In other cases, transfer/discharge forms were signed only by facility staff, with no evidence that the resident or their representative received or acknowledged the notice. Staff interviews confirmed that the expected process was not consistently followed, and some staff were unaware of the requirements for providing these notices. The facility also failed to provide or document the offering of bed hold notices to residents or their representatives when residents were transferred to hospitals. In multiple cases, there was no evidence in the medical records that bed hold policies were discussed or offered, and staff interviews confirmed that these forms were not completed or could not be located. Additionally, one resident was transferred to an acute care hospital without being provided a notice of transfer that included appeal rights and LTCO contact information. Staff acknowledged that it was not their practice to provide such notices, indicating a lack of awareness of regulatory requirements. Discharge planning was also insufficiently documented for some residents who expressed a desire to return to the community. In these cases, initial assessments indicated discharge goals and potential barriers, but there was no ongoing documentation of pre-discharge planning or progress notes by social services. Residents reported not being informed about their discharge plans, and staff confirmed that expected documentation and communication regarding discharge planning were missing from the records.