F0628

D

Failure to Provide Complete Bed-Hold Information and Ombudsman Notification for Hospital Transfer

Alamogordo, New Mexico Survey Completed on 02-16-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide required written transfer and bed-hold information for a hospitalized resident. Record review showed that one resident was admitted on an identified date and later sent to the hospital due to shortness of breath. The resident’s Bed Hold Notice Agreement, completed on the date of transfer, did not include documentation of the number of days the bed would be held. Interviews revealed that an RN routinely entered a default of three days for bed holds because nursing staff did not know the actual number of days available, and the Business Office Manager stated that nursing initiates the discharge/transfer while the Business Office determines the actual bed-hold days by contacting the family, typically the next day. This process resulted in the bed-hold notice lacking the required specific duration at the time of transfer.

The facility also failed to send required written transfer/discharge notices to the Ombudsman. The Social Service Clerk stated that she did not send notifications to the Ombudsman when the resident was discharged from the facility. The Administrator reported that Social Services was responsible for sending Ombudsman notifications and that she believed monthly notifications by email were acceptable, citing an email she sent covering a range of dates. However, record review of an email from the Ombudsman showed that the Administrator had been sending notifications to an incorrect email address. The facility’s Transfer and Discharge policy required complete documentation, written notice to residents and/or representatives, informing residents of their right to appeal, and notification of the Ombudsman, but these requirements were not met for the resident who was transferred to the hospital.