Failure to Provide Required Transfer, Bed Hold, and Ombudsman Notifications
Penalty
Summary
The facility failed to provide required written transfer and/or bed hold notices, as well as Ombudsman notifications, for two residents who were transferred to the hospital or discharged. One resident, who had severely impaired cognition and a healthcare Guardian, was transferred to the hospital on three separate occasions for medical issues including a brain bleed, complicated UTI, and pneumonia. On each occasion, neither the resident nor the Guardian received a written transfer or bed hold notice, and there was no documentation that the Ombudsman was notified of the transfers or the final discharge. Staff interviews confirmed that these notifications were not completed as required by facility policy. Another resident, also with severely impaired cognition and a healthcare Guardian, was discharged to an assisted living facility without documentation that the Ombudsman was notified of the discharge. Staff interviews further verified that Ombudsman notifications for transfers and discharges were missed during the relevant period. The facility's policy requires written notification to residents or their representatives regarding bed hold rights and transfer/discharge, as well as notification to the Ombudsman, but these steps were not followed for the residents in question.