Failure to Provide Required Written Discharge and Bed-Hold Notices on Hospital Transfers
Penalty
Summary
Facility staff failed to provide required written notice of discharge, including bed-hold policy and notification to the Long Term Care Ombudsman and State Agency, for two residents who were transferred to the hospital. The first resident was admitted with multiple diagnoses including difficulty walking, muscle weakness, severe anemia, and fibromyalgia, and had a MDS BIMS score indicating severely impaired cognition. A nursing progress note documented that the resident sustained a fall in her room, was found on the floor with swelling and a superficial open area on the right forehead, and was transferred to the emergency room per NP order for further evaluation and treatment. The care plan documented the fall and the intervention to transfer the resident to the ER. Upon record review, there was no documented evidence that written notification of the resident’s discharge, including bed-hold information and required notices, was provided. The second resident was admitted with diagnoses including stroke with left-sided hemiplegia, hypertension, diabetes mellitus, and deep vein thrombosis, and had an admission MDS BIMS score of 15, indicating intact cognition. A social worker progress note documented that the family requested a hospital transfer, was informed there was no medical reason for transfer but that they had the right to proceed, and that the facility completed the transfer with non-emergency transport to the hospital. A physician order documented that the transfer was per the resident’s request. Record review showed no documented evidence that written notification of the discharge, including bed-hold policy and required notifications, was provided. During an interview, the Director of Social Work acknowledged the absence of the required Notice of Discharge, Transfer or Relocation form in the records and could not explain why it was not filed.
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