Failure to Provide Required Written Bed-Hold Notices and Ombudsman Notification During Resident Transfers
Penalty
Summary
Surveyors identified that the facility failed to provide required written documentation and notifications related to bed-hold policies, transfer/discharge reasons, and appeal rights to residents and their representatives during hospital transfers or discharges. In all ten cases reviewed, there was no evidence that residents or their representatives received written notices specifying the reason for transfer/discharge or the facility's bed-hold policy, including the reserve bed payment rate for all payer sources after 15 days. Additionally, the facility did not notify the Ombudsman of these transfers or discharges as required by regulation and facility policy. The review of medical records and interviews with facility staff revealed inconsistent and unclear processes for completing and distributing transfer/discharge notices and bed-hold information. Staff members, including the Social Services Director, Medical Records Director, and Unit Secretary, provided conflicting accounts of their responsibilities, and there was confusion regarding who was responsible for notifying the Ombudsman. Documentation practices were inconsistent, with verbal consent often noted in place of written notification, and the required bed-hold payment rates were not included on the forms provided to residents or their representatives. In several instances, staff indicated that forms were only sent to representatives upon request, and there was no documentation that written notices were provided. The deficiency affected residents with a range of complex medical conditions, including seizures, neurogenic bowel, hemiplegia, diabetes, heart failure, chronic kidney disease, and others. Despite multiple hospital transfers for acute changes in condition, there was no evidence that the facility provided the necessary written information to residents or their representatives regarding their rights, the reason for transfer, or the financial implications of bed-hold policies. The facility also failed to maintain documentation of notifications to the Ombudsman for any of the reviewed cases.