Failure to Provide Required Transfer, Bed-Hold, and Ombudsman Notifications
Penalty
Summary
The facility failed to provide required written notifications and documentation regarding transfer, bed-hold policies, and appeal rights for two residents who were hospitalized. One resident, who was cognitively intact and responsible for their own healthcare decisions, was transferred to the emergency department due to a toe injury but did not receive a written transfer or bed hold notice. The facility also did not notify the Ombudsman of this transfer. Staff interviews revealed confusion about when to complete and provide these notices, with one nurse admitting to shredding the forms under the mistaken belief that they were only necessary for hospital admissions, not transfers. Another resident, who had moderate cognitive impairment and an activated Power of Attorney for Healthcare, was transferred to the hospital for cellulitis. The medical record indicated only verbal notification was provided, with no evidence that a written transfer or bed hold notice was given or mailed to the resident or their representative. Additionally, the Ombudsman was not notified of this transfer. Staff interviews confirmed inconsistent practices regarding the provision and documentation of these notices, and the facility's discharge notifications to the Ombudsman did not include residents transferred with a bed hold, contrary to regulatory requirements.