Failure to Notify Ombudsman and Provide Bed Hold Policy Information During Hospital Transfers
Penalty
Summary
The facility failed to notify the Office of the Long-Term Care Ombudsman regarding the hospital transfers of two residents. For one resident with diagnoses including orthostatic hypotension, vertigo, depression, and a left artificial hip joint, the clinical record showed a hospital admission for a left hip hemiarthroplasty. There was no evidence in the electronic medical record or nurse's notes that the Ombudsman was notified of this transfer, and staff interviews confirmed that notification was not completed at the time of transfer, but rather was typically done at the end of the month. Another resident, with diagnoses of schizophrenia, diabetes mellitus type 2, chronic pain, left lower extremity amputation, and dementia, was transferred to the hospital for a scheduled amputation. The clinical record lacked documentation that the resident or their family received written notification of the facility's bed hold policy prior to transfer, and there was also no evidence that the Ombudsman was notified of the transfer. Staff interviews confirmed that the bed hold notification was not provided and that Ombudsman notification was missed. Facility policies required that residents and/or their representatives be notified in writing of impending transfers or discharges, including the reasons for the move, and that a copy of the notice be sent to the Ombudsman. Policies also required that written information about bed hold policies be provided to residents or their representatives at the time of transfer. These requirements were not met for the two residents in question, as documented in the clinical records and confirmed by staff.