Failure to Provide Required Written Transfer and Bed-Hold Notices
Penalty
Summary
The facility failed to provide required written notices of transfer and bed-hold policies to residents or their representatives when residents were transferred to the hospital. Policy review showed the facility’s "Discharge Process and Bed Holds" policy, reviewed 12/1/25, required that before a transfer or discharge, the facility must notify the resident and representative in writing, in a language and manner they understand, of the transfer or discharge and the reasons for the move. The policy also required that before a resident is transferred to a hospital or goes on therapeutic leave, the facility must provide written information specifying the duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence. Record review revealed that one resident with multiple diagnoses including stage IV pressure ulcers, diabetes, and spinal cord injury was transferred from the facility and admitted to the hospital on two occasions, and there was no documentation that he was provided with a Notice of Transfer or Bed Hold Policy prior to either transfer. Another resident with multiple diagnoses including cancer, hypertension, and lumbar spinal stenosis was transferred and admitted to the hospital, and her medical record also lacked documentation that she was provided with a Notice of Transfer or Bed Hold Policy prior to transfer. During an interview on 3/18/26 at 1:40 PM, the DON stated they did not have the Notice of Transfer or Bed Hold documentation for these two residents.
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