Failure to Provide Required Written Transfer and Bed-Hold Notices
Penalty
Summary
The facility failed to provide a written notice of the reason for a facility-initiated transfer or bed hold to a resident or the resident's representative. One resident was discharged from the facility to a local hospital, and review of the electronic medical record showed a discharge date but no transfer or bed hold notices. The resident did not return to the facility following this transfer. When surveyors requested the transfer and bed hold notice for this resident, the facility produced a document stating there was no bed hold present for the transfer on that date. During interviews, one staff member stated that residents who transferred to the hospital for urgent evaluation would sign a bed hold and transfer notice form, and that the nurse transferring the resident would complete it, but she did not know if a form was filled out for this resident. Another staff member stated that residents who transferred from the facility signed a transfer notice and a bed hold notice form, and that nurses would assist residents to sign if they were unable. Review of facility policies showed that written discharge or transfer notices, including the reason, effective date, and location, must be provided and a copy maintained in the clinical record, and that bed-hold notices must be provided in writing in advance and again at the time of transfer or within 24 hours for emergency transfers. These required notices and documentation were not present in the resident's record.
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