Failure to Provide Written Transfer/Discharge Notices and Bed-Hold Policy
Penalty
Summary
The deficiency involves the facility’s failure to provide required written notifications of transfer/discharge to the hospital and to provide or document provision of the bed-hold policy to residents and/or their Resident Representatives (RRs). For Resident #1, who was cognitively intact and her own RR, the medical record showed two hospital transfers. For the first transfer, there was no documentation that she received written notification of the reason for transfer/discharge or a copy of the bed-hold policy. For the second transfer, the record again lacked documentation of written notification of the reason for transfer/discharge, although the bed-hold policy was provided. In an interview, Resident #1 stated she had not received written notification of the bed-hold policy or the transfer/discharge notice when she was transferred to the hospital. For Resident #60, who had moderately impaired cognitive skills and could not complete the BIMS, the record showed a hospital transfer with no documentation that the resident or RR received written notification of the reason for transfer/discharge or a copy of the bed-hold policy. In an interview, the RR confirmed not receiving written notification of the transfer/discharge or the bed-hold policy. The Social Worker reported that the Business Office Manager was responsible for providing the bed-hold policy when a resident was transferred, and also stated she was not aware she was responsible for written transfer/discharge notifications. The Business Office Manager stated she typically followed up within 24 hours and sent a handwritten bed-hold policy the next day after transfer, but could not locate evidence that the bed-hold policy had been provided for this resident. For Resident #34, who was cognitively intact, the record showed a hospital transfer with no documentation that the resident or RR received a copy of the bed-hold policy. The RR stated she did not receive the bed-hold policy but did receive written notification of the transfer, and she had coordinated the surgery date with the DON, knowing the resident would return to the same bed. The DON stated that during the week of this transfer the Business Office Manager was out of the office, and the DON communicated with the RR by email about the upcoming surgery but did not email the bed-hold policy and was not aware it needed to be mailed. Throughout interviews, the Administrator stated that the Social Worker was responsible for written transfer/discharge notifications and the Business Office Manager was responsible for ensuring the bed-hold policy was completed and mailed, but was unable to explain why the required notices and policies were not sent or documented for these residents.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.