Failure to Provide Bed-Hold and Ombudsman Transfer Notifications for Unplanned Hospital Transfers
Penalty
Summary
The deficiency involves the facility’s failure to provide required notifications related to emergent hospital transfers and bed-hold rights for two residents. For Resident 1, who had diabetes mellitus and moderate cognitive deficits with a BIMS score of 12/15, nursing staff identified a change in condition when the resident complained of shortness of breath late at night. A licensed nurse obtained orders for a STAT chest X-ray and a breathing treatment, but the resident’s condition continued to decline, and the resident requested transfer to the hospital. Emergency medical services transported the resident to the hospital in the early morning hours. Review of the medical record showed that the 24-hour bed-hold notification section was not signed, and there was no documentation that a Notice of Transfer was sent to the California Long-Term Care Ombudsman Program. Interviews with staff clarified the facility’s internal process and confirmed the lack of required notifications for Resident 1. The Medical Records Director stated that the former Social Services Director was responsible for discharge and transfer notifications, including ombudsman notification, and that Medical Records was responsible for completing and faxing the Notice of Transfer to the ombudsman for unexpected hospital transfers. The Medical Records Director acknowledged that this process was not completed for Resident 1. The Social Services Director stated that Social Services handled advance discharge notifications and obtained fax confirmations, while Medical Records was responsible for ombudsman notification for unplanned hospital transfers, and that nursing staff were responsible for notifying residents and/or responsible parties of the 24-hour bed-hold policy. For Resident 2, who had congestive heart failure and severe cognitive deficits and was rarely or never understood, a licensed nurse reported that the resident experienced hypoxia and that the physician and the resident’s conservator were notified. The resident was assessed by a nurse practitioner, labs were ordered, and the resident was later transferred to the hospital due to hypoxia. Record review for this resident showed there was no documentation of a bed-hold notification or a Notice of Transfer to the ombudsman in the requested records. Although the Medical Records Director stated that the ombudsman was notified of Resident 2’s transfers, the record lacked evidence of such notification. The facility’s transfer or discharge policy indicated that appropriate notice was to be provided to the resident and/or legal representative, but the survey findings showed that required notifications and confirmations related to bed-hold rights and ombudsman notification were not documented for these unplanned hospital transfers.
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