F0628

E

Failure to Provide Bed-Hold Notices and Ombudsman Discharge Notifications

Saint Louis, Missouri Survey Completed on 02-04-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in the facility’s failure to provide residents and/or their representatives with the required bed-hold policy information at the time of transfer to the hospital or as soon as practicable. Record review showed that between 9/1/25 and 2/2/26, 31 residents were transferred to acute care hospitals, yet the facility did not have documentation that the bed-hold policy had been provided for these transfers. During interview, the Administrator stated that floor nurses were responsible for giving the bed-hold policy at the time of transfer and acknowledged that the facility did not have the bed-hold documentation for residents who were transferred to the hospital.

Surveyors also found that the facility failed to send copies of discharge notices to the Office of the State LTC Ombudsman as required by the facility’s own Transfer and Discharge policy dated 4/1/22. That policy required that a copy of the discharge notice be sent to the Ombudsman for 30-day facility-initiated discharges, planned discharges and transfers to the hospital initiated by the facility, and unplanned discharges where the facility decided to discharge the resident while hospitalized. Review of Ombudsman notifications showed the last notification was in July 2025, and the Ombudsman representative reported the last transfer log received was from August 2025. The facility also lacked copies of discharge notices after July 2025, despite 15 residents being discharged home and three discharged to another facility during the review period.