Failure to Provide Written Hospital Transfer Notices and Bed-Hold Information
Penalty
Summary
The deficiency involves the facility’s failure to provide required written transfer notices and bed-hold information to residents and/or their representatives in connection with hospitalizations. One resident was admitted to the facility and later sent to the hospital due to weakness; review of the entire medical record showed no documented written notice of transfer for this hospitalization. The Regional Clinical Nurse confirmed that staff did not complete a transfer notice for this hospital transfer and stated that staff were expected to complete a written transfer notice when a resident was transferred to the hospital and to give a written copy to the resident or their representative. Another resident, admitted earlier in the year, was sent to the hospital for hypotension, and record review similarly revealed no documented transfer notice for that hospitalization; the Regional Clinical Nurse confirmed that no transfer notice was present and that a notice should have been provided. A third resident, admitted in mid-year, was sent from dialysis to the hospital, where a CT scan revealed pyogenic (septic) arthritis of the right hip, and was later transferred to another nursing home at the family’s request. The Social Service Worker stated that the facility learned of the hospital transfer from the dialysis center, did not recall notifying the ombudsman when the resident transferred to another nursing home, and indicated that nursing staff were responsible for admission documentation for bed holds and transfers. The Regional Clinical Nurse confirmed there was no bed-hold notice in this resident’s record and that staff were expected to complete the state bed-hold notice.
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