Failure to Notify Ombudsman and Provide Proper Bed Hold/Transfer Notice
Penalty
Summary
The facility failed to notify the ombudsman of resident discharges and did not provide a transfer notice and bed hold policy to the resident and/or resident representative for one of three residents reviewed for discharges. Specifically, for a resident admitted with thrombocytopenia and anemia, who was cognitively intact, the documentation related to their transfer to the hospital for gastrointestinal bleeding was incomplete. The Bed Hold/Transfer Notice form was not properly filled out, lacking details about the reason and destination for the transfer, and was not signed by the resident, only by the nurse. There was also no evidence that the resident or their representative received a copy of the notice. Interviews with facility staff revealed that ombudsman notifications for discharges were missing for the months of July and August, with only September notifications available. The Director of Nursing and Social Worker confirmed the absence of required notifications, attributing it to staffing vacancies. The facility's policy requires that a signed and dated copy of the bed-hold notice be provided to the resident or representative and kept in the medical record, but this was not followed in the reviewed case.