Failure to Provide Required Transfer/Discharge Notices and Bed Hold Policy
Penalty
Summary
The facility failed to provide written notification to resident representatives regarding the reason for unplanned transfers or discharges to the hospital and did not supply the required bed hold policy information for three out of four residents reviewed for hospitalizations. In the case of one resident with severe cognitive impairment, there was no documentation that the bed hold policy had been provided to the resident or their representative, and the notice of transfer form was incomplete, with the section for mailing to the representative left blank. The resident's representative confirmed that neither a bed hold notice nor a letter of transfer was received during the hospitalization. For another resident who was cognitively intact, the clinical records did not show that the bed hold policy was provided when the resident was transferred to the hospital after becoming nonresponsive. Nursing staff reported that the bed hold policy was not included in the transfer packet, and the admissions director stated she was not responsible for providing this information at the time of hospital discharge. This resident did not return to the facility and was later admitted to hospice care. A third resident, also severely cognitively impaired, was transferred to the hospital and later returned, but there was no documentation of the reason for transfer or that bed hold information was sent to the representative. Interviews with staff revealed confusion and lack of clarity regarding responsibility for providing the bed hold policy and completing transfer/discharge notifications. The administrator acknowledged awareness of the need for such documentation but noted that recent staff changes had contributed to lapses in providing required notifications and bed hold information.