Failure to Provide Bed-Hold Notice and Timely Ombudsman Discharge Notification
Penalty
Summary
The deficiency involves the facility’s failure to provide required written bed-hold notification at the time of a resident’s transfer and failure to notify the local ombudsman of resident discharges. For one resident who fell while self-transferring from a wheelchair to a toilet and was subsequently transferred to the hospital via 911, the medical record contained a transfer summary and documentation that the family, on-call medical provider, and ombudsman were notified of the incident. However, there was no written copy of the facility’s bed-hold notification form in the resident’s medical record for that hospital transfer, despite facility policy requiring that a copy of the bed-hold form be given to every resident or representative at the time of transfer outside the facility. The deficiency also includes the facility’s failure to notify the local ombudsman of resident discharges in a timely manner for two residents. One resident was sent to the hospital and did not return, and another resident expired in the facility. Review of records and e-mails showed that the ombudsman was notified of these discharges and other discharges, hospitalizations, and admissions only later via e-mail, rather than at the time of the events. The Business Office Manager confirmed that the ombudsman had not been notified in a timely manner and stated she had not initially been aware that ombudsman notification was her responsibility.
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