Failure to Provide Required Transfer and Bed Hold Notices During Hospitalizations
Penalty
Summary
Surveyors identified that the facility failed to provide required transfer and bed hold notices to residents and/or their representatives when residents were transferred to the hospital. Multiple residents experienced acute changes in condition, such as chest pain, shortness of breath, seizures, altered mental status, and vomiting, which led to their hospitalization. Despite these transfers, there was no documentation in the medical records that the residents or their representatives received written notification regarding the transfer, the reason for transfer, the location, appeal rights, or contact information for the State Long-Term Care Ombudsman. The facility also did not provide written information on the duration of the bed hold policy, the reserve bed payment policy, or the right to return to the facility. This deficiency was confirmed through interviews with facility leadership, who acknowledged that the process for providing these notices had lapsed due to the responsible staff member being on leave. The facility's own policies require that such notices be given at the time of transfer and that a signed and dated copy be kept in the resident's file, but these procedures were not followed for any of the residents reviewed. The lack of required documentation and notification was consistent across all residents reviewed for hospitalization, with no evidence that any of the affected residents or their representatives received the mandated information. The deficiency was further substantiated by the absence of transfer and bed hold notices in the residents' medical records and by statements from facility leadership confirming the failure to provide these notices.