Failure to Communicate Transfer Information and Provide Bed-Hold Notices
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to receiving health care providers during facility-initiated transfers for three of four sampled residents and failed to provide required written bed-hold policy notifications at the time of hospital transfer. Facility policies dated 5/19/25 required that, upon transfer or discharge, details be documented in the medical record and appropriate information be communicated to the receiving provider, and that residents or their representatives receive written information about bed-hold policies both in advance (at admission) and at the time of transfer. For each of the three residents, clinical record review showed no documented evidence that specific information such as care plan goals, advance directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident’s specific needs was communicated to the hospital. Resident 1, with diagnoses including atherosclerotic heart disease, COPD, and dysphagia, was transferred to the hospital and remained there, but the record lacked documentation of the required transfer information and written bed-hold policy notice at the time of transfer. Resident 2, with high blood pressure, depression, and muscle weakness, was transferred to and returned from the hospital the same day, yet the record similarly lacked documentation of communicated care plan goals, advance directives, ongoing care instructions, representative information, and written bed-hold policy notice. Resident 3, with atrial fibrillation, high blood pressure, and cerebral infarction, was transferred to the hospital and returned the following day, and the record again showed no documented evidence of the required transfer communication or written bed-hold policy notice at the time of transfer. In an interview, the Director of Nursing confirmed these failures for the three residents, in violation of 28 Pa. Code: 201.29 (a)(c.3)(2) regarding resident rights.
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