Failure to Provide Required Transfer, Discharge, and Bed Hold Notices
Penalty
Summary
A resident with diagnoses including dementia, anxiety, and a history of alcohol abuse, who rarely or never made decisions regarding daily living, eloped from the facility and was subsequently sent to the hospital for evaluation and treatment. The facility failed to provide a bed hold notice to the resident or their conservator upon transfer to the hospital, and there was no documentation of a discharge summary in the clinical record. Additionally, the discharge notice provided to the resident was dated several weeks after the actual discharge date, and the notice was not issued to the resident, conservator, or ombudsman on the day of discharge as required. Interviews revealed that the hospital social worker received documentation from the conservator regarding a meeting with the facility to discuss a safe discharge plan, but later received a letter from the facility refusing to readmit the resident. The ombudsman confirmed that the facility did not follow the required consultative and involuntary discharge processes, failed to issue timely discharge notices, and did not allow the resident to return while an appeal was pending. The conservator reported not receiving or signing discharge paperwork and indicated that the resident's bed and belongings remained at the facility, with no bed hold notice issued. The facility administrator acknowledged not issuing the required notices at the appropriate time and not initiating the consultative process with the hospital. The administrator also confirmed that the discharge notice was backdated and only filed after being informed of the correct process by the ombudsman. The facility continued to refuse readmission of the resident during the appeal process, contrary to regulatory requirements and facility policy.