Failure to Provide Required Transfer Notices and Ombudsman Notification
Penalty
Summary
The facility failed to provide required documentation and notifications related to resident transfers for three residents. Specifically, when residents experienced a change in condition and were transferred to the hospital, the facility did not provide a Notice of Bedhold or a written Notice of Transfer to the residents or their representatives. Additionally, there was no documentation that the Ombudsman was notified of these transfers. This deficiency was identified through record review and interviews, which confirmed the absence of these required notifications for all three residents involved. One resident with an activated Power of Attorney was transferred to the hospital on two separate occasions following falls, but neither a Bedhold notice nor a Notice of Transfer was provided to the representative, and the Ombudsman was not notified. Another resident with a legal guardian was transferred to the hospital without the required notifications being given. A third resident, who was her own decision maker and had diagnoses of multiple sclerosis and neurogenic bladder, was also transferred to the hospital without documentation of a Bedhold notice, written transfer notice, or Ombudsman notification. The Nursing Home Administrator confirmed that these notifications were not provided and was unaware of the requirements for issuing them at the time of each transfer.