Failure to Provide Required Bed-Hold and Transfer/Discharge Notices With Appeal Rights
Penalty
Summary
The deficiency involves the facility’s failure to provide required written bed-hold and transfer/discharge notices, including appeal rights information, to residents who were transferred to the hospital. For one resident (R2), who had metastasized prostate cancer, a stage 4 pressure ulcer to the right heel, opioid dependence, spinal stenosis of the cervical region, chronic pain, and moderate cognitive impairment, the record showed a hospital transfer on 1/23/26 due to chronic pain and refusal of care. R2 had an activated POA assisting with healthcare decisions. Interviews with the POAs indicated that the Admissions Coordinator informed them that R2 was being kicked out and would not be allowed to return because of complaints of pain, behaviors, refusal of care, uncontrolled pain, and combative behavior. The medical record did not contain any written bed-hold or transfer/discharge notice for R2 or the POAs, and the Admissions Coordinator confirmed that no such notice or discussion occurred. The DON confirmed that no bed-hold or transfer/discharge notice was reviewed or provided because the facility would not accept R2 back and stated unawareness of the requirement to provide such notices, including information on return rights and appeal rights, for all residents transferred to the hospital. For another resident (R13), who had acute on chronic combined systolic and diastolic congestive heart failure, aspiration pneumonia, and intact cognition with responsibility for their own healthcare decisions, the record showed a hospital transfer on 2/1/26. R13’s signed “Bed-Hold for Hospitalization and Therapeutic Leave/Discharge” form was present but lacked required information on appeal rights. Specifically, the form did not include the name, mailing and email address, and telephone number of the entity that receives appeal requests, nor did it provide information on how to obtain an appeal form or receive assistance with completing and submitting an appeal hearing request. The DON stated they were not aware that bed-hold and transfer/discharge notices must include information on appeal rights and verified that the facility’s form did not contain the required appeal information. The DON also indicated that this same form functioned as the facility’s policy and that there was no separate bed-hold or transfer/discharge policy.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.