Failure to Provide Required Bed Hold and Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide required written notices of bed hold, transfer, and discharge to residents, their representatives, and the State Ombudsman in cases of hospitalization and discharge. For three residents reviewed, documentation was missing regarding the issuance of bed hold policies and transfer/discharge notifications during hospital transfers or discharges. Specifically, one resident was hospitalized and re-admitted without any progress notes or EMR documentation indicating that a bed hold or transfer/discharge notice was offered or provided. Staff interviews revealed confusion and inconsistent practices regarding who was responsible for completing and sending these notifications, with some staff unaware of the requirement to notify the State Ombudsman for hospital transfers or unplanned discharges. Additionally, for another resident who was sent to the emergency room, there was no evidence in the EMR that the State Ombudsman was notified. In the case of a resident discharged to an adult family home, the EMR lacked documentation of notification to the State Ombudsman. Staff reported that notifications for planned discharges were sent monthly, but could not provide documentation that notifications were sent for each individual discharge as required. The facility's own policy required timely notification and documentation, but these procedures were not consistently followed.