Failure to Provide Required Transfer Notices and Bed Hold Policy Information
Penalty
Summary
The facility failed to provide required transfer notices and bed hold policy information to residents or their representatives upon transfer or discharge, as mandated by facility policy and state regulations. Specifically, for three residents with significant medical conditions, including congestive heart failure, chronic kidney disease, vascular dementia, atrial fibrillation, infection following a procedure, dysphagia, and repeated falls, there was no documentation that they or their representatives received written notice of transfer or the facility's bed hold policy during multiple hospitalizations and returns. Facility policy requires that all residents or their representatives receive written information about bed hold policies both in advance of any transfer and at the time of transfer, or within 24 hours if the transfer is emergent. Clinical record reviews for these residents showed multiple instances of hospital transfers due to acute medical changes, but no evidence was found that the required notices were provided. The Nursing Home Administrator confirmed that there was no proof these notices were sent for the identified transfers. This deficiency was identified through facility policy review, clinical record review, and staff interviews, and is a violation of 28 Pa. Code 201.14(a) regarding the responsibility of the licensee.