Failure to Provide Required Written Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide required written notices of transfer or discharge, appeal rights, and bed-hold information to resident representatives, and to notify the LTC ombudsman, for multiple residents who were hospitalized or discharged. For one resident with diagnoses including pneumonia, atrial flutter, acute respiratory failure with hypoxia, malignant neoplasm of the colon, and obstructive and reflux uropathy, nursing documentation showed the resident was transferred to the ER and the daughter was notified verbally, but there was no indication that a written notice of transfer or discharge was provided. For another resident with anxiety disorder, major depressive disorder, catatonic disorder due to a known physiological condition, mood affective disorder, type 2 DM, edema, and metabolic encephalopathy, the record showed a physician ordered transfer to the hospital for psychiatric evaluation, and a progress note documented a Zoom visit with a psychiatric physician followed by transport by family. The transfer/discharge report indicated the son was notified of the transfer but did not show that a written notice or bed-hold policy was provided at the time of transfer. A third resident, with diagnoses including metabolic encephalopathy, contusion of the right thigh, acute and chronic respiratory failure with hypoxia, pulmonary fibrosis, bronchiectasis, acute on chronic diastolic CHF, anxiety disorder, and moderate dementia with mood disturbance, was discharged to an assisted living memory care apartment. Progress notes documented the planned discharge and the actual discharge, but there was no documentation that the resident representative received a written notice of transfer or discharge or the bed-hold policy. Interviews with the Executive Director and Social Services Director confirmed that the facility had been providing only verbal notifications to resident representatives and had not consistently issuing written transfer/discharge notices, bed-hold information, or notifying the ombudsman for both emergent hospital transfers and scheduled discharges, contrary to the facility’s own “Transfer Emergency Discharge” policy requiring written notices to the resident, representative, and ombudsman.
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