Failure to Provide Written Transfer/Discharge and Bed Hold Notices
Penalty
Summary
The facility failed to provide a written notice of transfer or discharge and did not issue a bed hold notice with the required information for a resident who was hospitalized. The resident had diagnoses of hypotension and Parkinson's disease, with a documented history of falls and moderately impaired cognition. The care plan indicated the resident planned to return home, and the resident was transferred to the hospital by ambulance after being found on the floor by her bed. Administrative staff confirmed that neither the resident nor her legal representative received written notification or bed hold information at the time of the facility-initiated transfer. The facility's policy required that bed hold information be provided at the time of transfer, with social services responsible for delivering the written notification and follow-up. The deficiency was identified through observation, record review, and staff interviews, which confirmed the lack of required documentation and notification.