Failure to Provide Required Transfer, Discharge, and Bed Hold Notices
Penalty
Summary
The facility failed to provide required documentation and notifications related to a resident's transfer to a General Acute Care Hospital (GACH). Specifically, the facility did not issue a written notice of bed hold to the resident at the time of transfer, despite the policy requiring such notice both at admission and at the time of transfer or within 24 hours if the transfer was emergent. Although the resident had previously declined a bed hold during admission, the facility did not provide the required written notice at the time of the hospital transfer, as confirmed by both the DON and the Administrator during record reviews and interviews. Additionally, the resident was not given a written notice of transfer or discharge in a manner that could be understood, nor was the required notice sent to the Ombudsman’s office. The facility staff considered the transfer to be facility-initiated due to the resident's condition at the time of transfer, but did not provide the necessary documentation or notifications. The DON and Administrator both confirmed that the notice of transfer or discharge was not issued to the resident or the Ombudsman, contrary to facility policy and regulatory requirements. As a result of these failures, the resident was not fully informed of their rights regarding bed hold, return to the facility, or the right to appeal the discharge. The lack of notification and documentation led to the resident experiencing a prolonged stay in the hospital emergency room and a temporary loss of residence, which resulted in emotional distress for the resident.