Failure to Provide Bed Hold and Hospital Transfer Notification
Penalty
Summary
The facility failed to provide a written notice of bed hold and a written notification of hospital transfer to a resident and their representative when the resident was transferred to the hospital. The resident, who had diagnoses including intellectual disabilities and epilepsy, experienced loose stools and an elevated temperature over three days. Following provider notification, the resident was sent to the hospital and subsequently admitted with sepsis. Review of the medical record confirmed that neither the resident nor their representative was offered a bed hold or given a notification of the hospital transfer. Interviews with facility staff revealed that the Social Services Specialist did not receive or missed the email notification regarding the resident's hospital admission, resulting in the omission of both the bed hold offer and the transfer notification. The Administrator acknowledged that the expected process was not followed, and the required notifications were not completed according to facility policy.