Failure to Provide Required Bed Hold and Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide required bed hold notices and transfer/discharge notifications to residents or their representatives when residents were transferred to the hospital. Specifically, three residents with various medical conditions, including diabetes, chronic kidney disease, Alzheimer's disease, peripheral vascular disease, and osteomyelitis, were transferred or discharged without documentation that they or their representatives received written bed hold or transfer/discharge notices. In addition, there was no documentation that the ombudsman was notified of these transfers or discharges as required. Interviews with the Director of Nursing confirmed the absence of this documentation for all three residents reviewed. Medical record reviews revealed that one resident with severely impaired cognition and another who was cognitively intact did not receive the required notifications upon transfer to the hospital. Another resident, who was readmitted after a hospital stay, also did not receive a formal bed hold notification, despite being verbally informed of a nine-day bed hold. Facility policies reviewed indicated that written notification should be provided prior to transfers, but this was not followed in these cases.