Failure to Provide Bed-Hold Notices and Notify Ombudsman of Transfers and Discharges
Penalty
Summary
Surveyors identified that the facility failed to provide required bed-hold notices to two residents and failed to notify the ombudsman of transfers and discharges for three residents. One resident was transferred from the facility to the hospital and did not return, instead being discharged to another placement with family; another resident was transferred to the hospital and later expired there; and a third resident had a planned discharge from the facility. For the two residents who were transferred to the hospital, there was no documentation in the electronic medical record that a bed-hold notice was provided to them or their representatives at the time of transfer or during hospitalization. Staff interviews confirmed that nursing did not send out bed-hold notices on transfer and that no additional bed-hold notices were sent after admission because residents received a copy in their admission contract. The facility’s bed-hold policy described the bed-hold policy itself but did not specify when a copy of the notice should be provided to residents or their representatives. The survey also found that the facility did not notify the ombudsman of resident transfers and discharges for three reviewed residents. Record review showed no documentation that the ombudsman was notified of the transfer or discharge for the resident who went to the hospital and then to another placement, the resident who had a planned discharge, or the resident who was transferred to the hospital and later died there. The ombudsman stated that facilities should be notifying the ombudsman program of resident discharges and that this facility had not been doing so. The social services staff member reported she had not been notifying the ombudsman of transfers or discharges because she was unaware this was required, and the DON stated that nursing did not notify the ombudsman and she was unsure if anyone else did. The admissions liaison confirmed she did not send anything to the ombudsman. The administrator acknowledged that bed-hold notices were given on admission only and that there was no facility policy for ombudsman notification, and the facility was unable to provide a policy addressing ombudsman notifications.
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