Failure to Provide Required Written Bed-Hold Notice at Time of Hospital Transfer
Summary
The facility failed to provide a required written Bed-Hold notice to a resident’s responsible party (RP) at the time of the resident’s transfer to a general acute care hospital (GACH). The resident, who had diagnoses including respiratory failure with hypoxia, was originally admitted and later readmitted to the facility, and an H&P dated 2/21/2026 documented that the resident did not have the capacity to understand and make decisions. An MDS dated 3/10/2026 showed the resident was dependent for ADLs such as toileting hygiene, showering/bathing, and bed mobility. The resident was transferred to the GACH for a G-tube replacement, and the discharge summary documented this transfer. Review of the resident’s Bed-hold Informed Consent/Notification Form dated 2/21/2026 showed no indication that a Notice of Bed-hold was provided to the RP after the transfer on 3/10/2026. During interviews, the Business Office Manager stated that the nursing department was responsible for providing the Bed-Hold Notice to residents or their RPs. In a concurrent interview and record review, the DON stated that residents’ beds should be held for seven days when they are transferred to the GACH and that staff would verbally inform RPs about the bed-hold at the time of transfer. The DON also stated she was not aware that written notices should be provided to RPs and acknowledged that, according to the facility’s undated P&P titled “Bed-Holds and Returns,” a written second notice should have been provided to the RP at the time of transfer and that the facility did not follow this P&P. The P&P specified that all residents or representatives are to be provided written information about bed-hold policies at least twice: once in advance of any transfer (e.g., in the admission packet) and a second time at the time of transfer or within 24 hours if the transfer is an emergency.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0628 Discharge Process How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Resident 3 was immediately reviewed on 03/27/2026 following identification of the deficient practice. The facility verified that the resident was readmitted on 03/25/2026 without loss of bed or services. On 03/25/2026, the party responsible was contacted by the Director of Nursing (DON) and provided re-education regarding the facility's bed-hold policy, including the 7-day bed-hold provision. A written Bed-Hold Notice was issued retroactively and explained to the party responsible, with documentation placed in the medical record. The interdisciplinary team reviewed the discharge and transfer documentation to ensure all required elements were completed. No adverse outcome occurred. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A 12-day look-back audit was conducted by Medical Records Supervisor from 03/14/2026 through 03/26/2026 for residents transferred to the hospital or on therapeutic leave. The audit focused on compliance with written Bed-Hold Notice requirements at the time of transfer. A total of applicable transfer records was reviewed by the DON and Medical Records Supervisor. No additional residents were identified as missing, written Bed-Hold Notices at the time of transfer. All licensed nurses, unit managers, and admissions staff were re-educated on 03/27/2026 by the Development of Staff Development (DSD) on requirements for discharge documentation and bed-hold notification. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility will reinforce the systemic corrective actions on discharge process to ensure compliance with the requirements for discharge and bed-hold notification. A standardized Bed-Hold Notice process was incorporated into the transfer workflow, requiring completion of a written notice at the time of transfer or within 24 hours for emergency transfers. The Electronic Medical Record (EMR) was re-enforced to include a required field for Bed-Hold Notice documentation. Licensed nurses, admissions staff, and business office personnel were re-educated on 03/27/2026, by DSD to ensure understanding of regulatory requirements and facility expectations. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility will monitor compliance through a structured audit process integrated into the Quality Assurance and Performance Improvement (QAPI) program. Weekly audits of randomly selected residents who experienced hospital transfers will be conducted for four consecutive weeks by Medical Records Supervisor from 03/28/2026 through 04/25/2026, followed by monthly audits for three months from May through July 2026. Audits will evaluate the presence, timeliness, and completeness of written Bed-Hold Notices, including documentation in the EMR and notification of the responsible party. Audit results will be reviewed by the Director of Nursing and/or designee and reported to the QAPI Committee monthly. Any identified non-compliance will result in immediate corrective action, including documentation correction, staff re-education, and progressive discipline if indicated. After three months, the QAPI Committee will evaluate audit findings for trends; if no trends are identified, the monitoring process will be discontinued, and if trends persist, corrective actions and monitoring will be extended to ensure sustained compliance. Dates when corrective action will be completed. 4/17/2026
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with cerebral palsy and depressive disorder was transferred to the hospital, but the facility did not document completion of the required written bed hold notice for the resident or representative. The facility’s policy called for written bed hold notices at admission and again at transfer, and the SW confirmed the document was not completed.
The facility failed to give two residents written transfer notices and written bed-hold notices when they were sent to the hospital. Records showed one resident had moderate cognitive impairment and the other had intact cognition, but neither record showed a written notice with ombudsman info, appeal rights, or the required bed-hold details such as state policy duration, reserve bed payment policy, or facility bed-hold policy. Staff interviews indicated uncertainty about whether the notices were provided, and the nurse manager stated the facility did not have a process for written transfer notices.
Failure to Provide Bed-Hold Notice and Ombudsman Notification: The facility failed to give a written bed-hold notice when one resident was transferred to the hospital and failed to notify the State LTC Ombudsman of the discharge for two residents. One resident had streptococcal infection and respiratory failure and was transferred to the hospital, while another resident with surgical aftercare and morbid obesity was discharged after leaving AMA. The Administrator confirmed the Ombudsman had not been notified.
Failure to Provide Written Transfer or Discharge Notices: The facility did not give written transfer or discharge notices, with reasons for the move, to three residents or their representatives, and did not send copies to the State LTC Ombudsman. One resident had severe cognitive impairment and was transferred to the hospital twice, another had moderate cognitive impairment and was sent out after a fall and leg pain, and a third had a planned discharge home. The Social Worker and DON stated that only transfer forms or 30-day notices were handled, and the discharge policy did not require written resident notification.
Failure to Document Required Involuntary Discharge Notice: The facility transferred a resident to a sister facility without documented written notice of the involuntary discharge, appeal rights, resident or resident rep notification, attempted contact with the resident’s daughter, or Ombudsman notification. The SW and Administrator acknowledged missing discharge documentation, and the Ombudsman confirmed the required discharge process had not been followed.
The facility failed to notify a resident’s responsible party of the bed hold when the resident was transferred out, and failed to include another resident’s transfer/discharge on the monthly ombudsman report. Record review and staff interview showed the bed hold notice was given to the resident and mailed later to the family, but there was no documentation that the responsible party was notified at the time of transfer. The monthly Action Summary sent to the ombudsman also omitted a resident who was hospitalized and later discharged to another care facility.
Failure to Provide Bed Hold Notice at Hospital Transfer
Penalty
Summary
The facility failed to ensure that a written notice of transfer and bed hold policy was provided to the resident or the resident’s representative when the resident was transferred to the hospital. The facility’s Bed Hold policy dated 2/1/18 stated that two written notices of the bed hold policy and procedures would be issued to the resident, family member, or legal representative, with the first notice given upon admission and the second notice given at the time of transfer for hospitalization. Resident #4 was admitted with multiple diagnoses including cerebral palsy and depressive disorder. Record review showed no documentation of a written bed hold form being completed when Resident #4 was transferred to the hospital on 2/23/26, and the Social Worker stated that she had not completed a bed hold document for the resident when she was transferred in February 2026 and that she should have.
Failure to Provide Required Transfer and Bed-Hold Notices
Penalty
Summary
The facility failed to provide a written transfer notice and a written bed-hold notice for 2 residents who were transferred to the hospital. For one resident, the quarterly MDS indicated moderate cognitive impairment, and the census showed the resident was on hospital unpaid leave after transfer to the hospital; the progress note documented that the resident was transferred and the POA was contacted. For the second resident, the admission MDS indicated intact cognition, and the census and progress note showed the resident was sent to the emergency department and the significant other was notified. For both residents, the medical records did not show that a written transfer notice was given at the time of transfer, including information such as ombudsman information and appeal rights. The records also did not show that a written bed-hold notice was provided to the resident or resident representative with information such as the duration of the state bed-hold policy, the reserve bed payment policy, or the facility's bed-hold policy. During interviews, nursing staff stated they were unsure whether the written transfer and bed-hold notices were given, and the nurse manager stated the facility did not believe it had a process to give residents a written transfer notice and that emails to resident representatives about bed hold did not include the required policy information.
Failure to Provide Bed-Hold Notice and Ombudsman Notification
Penalty
Summary
The facility failed to provide a written Notice of Bed Hold Policy at the time of hospital transfer for Resident 76 and failed to notify the State Long-Term Care Ombudsman of the resident’s discharge. Resident 76 was admitted with diagnoses including streptococcal infection and respiratory failure, and the admission profile indicated the resident was responsible for self. The clinical record showed the resident was transferred to the hospital on 4/26/26, but there was no evidence that the resident or resident representative received the written bed-hold notice at transfer or that the Ombudsman was notified of the discharge. The facility also failed to notify the State Long-Term Care Ombudsman of Resident 78’s discharge. Resident 78 was admitted with diagnoses including surgical aftercare and morbid obesity, and the admission profile indicated the resident was responsible for self. The clinical record showed the resident was discharged after leaving against medical advice (AMA), but there was no evidence that the Ombudsman was notified of the discharge. The Administrator confirmed that the State Long-Term Care Ombudsman had not been notified of the transfer/discharge events for Residents 76 and 78.
Failure to Provide Written Transfer or Discharge Notices
Penalty
Summary
The facility failed to notify residents and/or their representatives in writing, in a language and manner they understood, of transfer or discharge and the reasons for the move, and failed to send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for three residents reviewed for discharge planning. The deficiency involved Resident #7, Resident #8, and Resident #77. Resident #7 was a female resident with diagnoses including NSTEMI, cognitive communication deficit, COPD, acute respiratory failure with hypoxia, and paranoid personality disorder. Her quarterly MDS showed a BIMS score of 3/15, indicating severe cognitive impairment. Progress notes documented that she was transferred to the hospital on 12/09/2025 for chest pain and shortness of breath, and again on 12/28/2025 for abnormal vital signs, altered mental status, and increased confusion. The record contained no evidence that a written transfer or discharge notice was provided to Resident #7 or sent to the State LTC Ombudsman. During interview, Resident #7 stated she did not remember receiving a written letter when sent to the emergency room and said she would have liked to receive one to give to her family member. Resident #8 was a female resident with diagnoses including COPD, type 2 diabetes mellitus without complications, morbid obesity, and chronic hypoxic respiratory failure. Her MDS showed a BIMS score of 12/15, indicating moderate cognitive impairment, and she required mostly substantial to maximal assistance with care. Progress notes documented that after a fall and complaint of leg pain, she was not willing to wait for the facility mobile x-ray, called 911, and was taken to the hospital. There was no evidence that a written transfer or discharge notice was provided to Resident #8 or sent to the State LTC Ombudsman. During interview, Resident #8 stated she had never received a written letter when sent to the hospital and said written information would have allowed her to review the details more carefully later. Resident #77 was a female resident with diagnoses including cognitive communication deficit, muscle wasting, hypokalemia, and diaphragmatic hernia. Her admission MDS showed a BIMS score of 11/15, indicating moderate cognitive impairment, and she required mostly setup or clean-up assistance. Progress notes documented a planned discharge home on 04/02/2026, and there was no evidence that a transfer or discharge notice was provided to the State LTC Ombudsman. The Social Worker stated she had not provided written notification to residents or their representatives regarding transfer or discharge, including the reason for the transfer or discharge, and said the only list sent to the State LTC Ombudsman was 30-day notices. The DON stated nursing staff only provided a transfer form to the hospital and that she did not send a list of discharged residents to the State LTC Ombudsman. The facility's discharge policy did not contain requirements for written notification to the resident or representative regarding discharge.
Failure to Document Required Involuntary Discharge Notice
Penalty
Summary
The facility failed to provide and document written notice of an involuntary transfer/discharge for R100 before the resident was transferred to a sister facility on 8/22/25. The resident’s EHR did not contain documentation of a Notice of Involuntary Discharge, notification of appeal rights, evidence that the resident and/or resident representative were notified, documentation of attempted contact with the resident’s daughter or resident representative, or notification to the Ombudsman program regarding the discharge. During interviews, the Social Worker stated the facility typically issued a NOMNC, discussed appeal rights, reviewed discharge information, coordinated with outside providers, and arranged transportation, but confirmed there was no documentation of attempts to contact the resident’s daughter or of discharge planning for this transfer. The Administrator stated the resident was transferred to the sister facility and that notice had been relayed to the resident, but she could not provide documentation supporting that notification and acknowledged missing pieces in the discharge record. The Ombudsman stated the required discharge process had not been followed, there was no evidence that a Notice of Involuntary Discharge had been issued or that the resident and/or resident representative had been notified, and the Office of Ombudsman for Long-Term Care had not received notification of the discharge.
Failure to Notify Responsible Party of Bed Hold and Report Resident Transfer to Ombudsman
Penalty
Summary
The facility failed to notify a resident’s responsible party of the bed hold policy at the time the resident was transferred from the facility for an emergency room transfer. Record review showed the resident was sent out with a copy of the bed hold policy, and later documentation indicated the policy was mailed to the resident’s family/responsible party on the next business day. However, there was no documentation in the resident’s record showing that the family or responsible party was notified of the bed hold when the transfer occurred. The Social Service Director confirmed that the facility’s process was to give the notice to the resident at transfer and mail it to the responsible party afterward, and the Regional Administrator confirmed there was no documentation showing the responsible party was notified at the time of transfer. The facility also failed to include a resident’s transfer or discharge on the monthly report sent to the ombudsman. Record review showed the resident was admitted to the hospital and later discharged from the facility after being admitted to another care facility from the hospital. The facility’s monthly Action Summary, which the Social Service Director identified as the report sent to the ombudsman, did not list this resident’s transfer or discharge during the reporting period. The Social Service Director confirmed the resident should have been included on the report but was not.
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