Failure to Provide and Document Bed-Hold and Transfer/Discharge Information During Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to provide required bed-hold policy and transfer/discharge documentation, and to document that these were given, when a resident was transferred to the hospital with a change in condition. The resident had been admitted with diagnoses including pneumonitis due to inhalation of food and vomit, severe protein-calorie malnutrition, non-pressure ulcers of the lower extremities, dementia, and peripheral vascular disease. The most recent MDS showed a BIMS score of 3/15, indicating severe cognitive impairment, and the resident required substantial assistance with ADLs and was dependent for toileting and perineal hygiene. Despite these needs, the record did not contain evidence that the resident or representative received the bed-hold policy or transfer/discharge paperwork at the time of the emergency transfer. Interviews and record review showed multiple communication and documentation gaps surrounding the resident’s change in condition and transfer. The resident’s family member reported concerns about his care, including a non-functioning call light that led the facility to provide a bell that staff could not hear, and she stated she was unsure the resident knew how to use it. A nursing progress note documented the wife’s complaint that the call light did not work and that the bell was not loud enough, her statement that he had received the worst care and that it was neglectful that no one could hear when he needed help, and that the resident was moved to a different room with a working call light. The prior DON acknowledged being informed of concerns about the call light, including that it had been placed in a dresser drawer out of the resident’s reach at some point, and also acknowledged not completing a grievance or concern form. On the day of the hospital transfer, the family member noticed a change in the resident’s responsiveness and questioned whether he should go to the hospital; she reported that an LPN told her he was not dying and that the hospital would not do anything but send him back. Later, the hospital notified her that the resident had been there for several hours, and she stated the facility had not called her about this change in condition. The LPN reported that the resident was initially fine but became unstable around dinner, that she obtained vital signs, placed him on oxygen, and called 911, and that she believed she called the wife and sent transfer/discharge paperwork, but then stated she was unsure and that it had been “kind of crazy” at the end of her shift. Record review confirmed there was no documentation that the provider was notified of the change in condition before transfer, no documentation that the resident or representative received the bed-hold policy or transfer/discharge paperwork, and no documentation that the wife was notified of the transfer. The unit manager and social worker both indicated that such paperwork should be completed and documented, but acknowledged that it was not evident in the record for this resident.
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