Failure to Provide Required Transfer and Bed-Hold Notices During Hospitalizations
Penalty
Summary
The facility failed to provide required written transfer and bed-hold notices to two out of three residents reviewed who were hospitalized. Specifically, the facility did not issue documentation to the residents or their representatives that included the date and reason for transfer, location of transfer, duration of bed-hold, appeal rights, and contact information for the State Long-Term Care Ombudsman. This omission was identified through interviews and record reviews, which revealed that no such notices were found in the electronic health records (EHR) for the residents in question. One resident with diagnoses including muscle wasting, acute and chronic respiratory failure, and a tracheostomy was transferred to the hospital on three separate occasions. Progress notes documented the clinical events leading to each transfer, such as labored breathing, trach removal, and sepsis, but there was no evidence that the required transfer and bed-hold notices were provided or documented in the EHR. Another resident with multiple chronic conditions and an activated healthcare power of attorney was also transferred to the hospital, and again, no written notice was found in the EHR for this event. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for issuing transfer and bed-hold notices. The Nursing Home Administrator, Social Services Director, Admissions Director, RN Unit Manager, and Health Unit Coordinator each gave differing accounts of who was responsible for providing and documenting these notices. Some staff believed the notice was only required at admission or monthly, rather than at each transfer, and others were unaware of the requirement altogether. This lack of consistent process and documentation led to the deficiency.