Failure to Provide Required Notifications and Protect Health Information During Transfer and Discharge
Penalty
Summary
The facility failed to provide required written notification of the bed hold policy to a resident's representative and did not notify the Ombudsman when a resident was transferred and discharged to the hospital. Specifically, for a resident with multiple diagnoses including muscle weakness, Alzheimer's disease, major depressive disorder, hypertension, osteoporosis, chronic kidney disease, and pain, there was no documentation that the bed hold policy was given in writing to the resident's representative or that the Ombudsman was notified of the hospital transfer. Interviews with facility staff confirmed these notifications were not completed or documented as required. Additionally, the facility failed to protect resident health information during the discharge process. When another resident was discharged to home, the caregiver received discharge paperwork that included another resident's personal health information. Staff interviews revealed that discharge paperwork is prepared by social services and reviewed by a nurse with the resident or family, but in this instance, the error was not caught before the paperwork was given to the caregiver. Facility policies require the protection of health information and proper notification procedures, but these were not followed in the cited incidents.