Failure to Provide Bed-Hold Notification and Ombudsman Notification During Transfers and Discharges
Penalty
Summary
The facility failed to provide required written bed-hold notifications and did not notify the LTC Ombudsman during resident transfers to hospitals and discharges home. Specifically, for four residents with various diagnoses including heart failure, kidney disease, weakness, stroke, and alcohol abuse, there was no evidence in the clinical records that written notice of the facility's bed-hold policy was given to the residents or their representatives at the time of transfer or hospitalization. Additionally, there was no documentation that the LTC Ombudsman was notified of these transfers or discharges, as required by facility policy. Interviews with facility staff, including the Administrator and Social Services Director, confirmed that written bed-hold notifications were not provided and that the Ombudsman was not notified for the affected residents. The lack of documentation and staff acknowledgment of these omissions demonstrate that the facility did not follow its own policies regarding resident notification and communication with the Ombudsman during transfers and discharges.