Failure to Provide Required Written Transfer and Bed-Hold Notices
Penalty
Summary
The facility failed to provide required written notices of transfer and bed-hold policies to a resident or the resident's representative when the resident was transferred to the hospital. Policy review showed the facility's "Discharge or Transfer" policy, revised 8/30/25, required that the resident, the resident's representative (if any), and the State Long-Term Care Ombudsman receive written notice at least 30 days before a transfer or discharge, except when urgent medical needs require an immediate transfer. The facility's "Bed-Hold" policy, revised 9/9/25, required that written information about bed-hold policies be provided to residents prior to and upon transfer for absences such as hospitalization or therapeutic leave. Record review and staff interview revealed that a resident admitted with multiple diagnoses including diabetes, heart failure, and cirrhosis was transferred to the ER on 9/22/25 and again on 2/8/26, and on both occasions the medical record lacked documentation that a written Notice of Transfer or bed-hold policy was provided. The RN Clinical Resource Nurse confirmed on 3/3/26 at 4:00 PM that they could not locate the Notice of Transfer or bed-hold documentation for either ER transfer. The deficient practice was identified for 1 of 2 residents reviewed for transfers and was determined to have the potential to create psychosocial distress if residents and their representatives were not made aware of or able to exercise their rights related to transfers from the facility.
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