Failure to Provide Required Transfer and Bed Hold Notices During Hospitalizations
Penalty
Summary
The facility failed to provide required transfer and bed hold notices to residents and/or their representatives during hospitalizations, as identified for three residents reviewed for hospitalization. Specifically, when residents were transferred to the hospital on multiple occasions, there was no documentation that the residents or their representatives received notices regarding the transfer, the reason for transfer, the location, appeal rights, or contact information for the State Long-Term Care Ombudsman. This deficiency was confirmed through interviews and record reviews, which showed that the facility had not been issuing these notices since switching to a new electronic medical record (EMR) system at the beginning of the year. The affected residents included individuals with significant medical conditions, such as a right leg fracture and chronic kidney disease, who experienced changes in condition necessitating hospitalization. Staff interviews revealed that the previous EMR system automatically generated the required notices, but the new system did not, resulting in a lapse in compliance. Despite some communication with families about bed hold options, there was no evidence that the formal transfer and bed hold notices were provided as required by facility policy and federal regulations.