Failure to Provide Required Written Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide written notice of transfer/discharge rights and the facility’s bed-hold policy to residents and/or their representatives when residents were transferred to the hospital. For one resident with cerebral infarction, atrial fibrillation, and vascular dementia, progress notes documented a change in condition with lethargy, garbled speech, and intermittent responsiveness, leading to a family request for transfer to the ER and subsequent transport by EMTs. The clinical record did not contain documentation that a Notice of Transfer rights or bed-hold policy was provided to the resident or her representative at the time of this hospitalization. A second resident with diagnoses including hyperosmolality, hypernatremia, tonsillar cancer, and nontraumatic subarachnoid hemorrhage experienced respiratory distress with moist respirations, labored breathing, and low oxygen saturation, prompting provider notification, an order for ER transfer, and EMS transport. Later that same month, the same resident had an unresponsive episode in the dining room with low oxygen saturation and decreased responsiveness, again resulting in provider notification and ER transfer. For both hospitalizations, progress notes documented the transfers and subsequent hospital admissions, but the clinical record lacked documentation that the Notice of Transfer rights and bed-hold policy were provided to the resident or his representative. A third resident with anemia, hypertension, and dementia exhibited a change in condition characterized by abnormal urine appearance and odor, altered mental status compared to baseline, and a family request for ER evaluation. The provider was notified, an order for ER evaluation was obtained, 911 was called, and the resident was transported and later admitted for urosepsis. The record did not show that the Notice of Transfer rights and bed-hold policy were provided to the resident or his representative. Interviews with the Social Services Director, DON, and an RN revealed that bed-hold paperwork and related forms were routinely placed in a packet sent with EMTs to the hospital, with no direct provision of these notices to residents or their representatives and no documentation that such notices were received, despite facility policy requiring that bed-hold and return policies be provided to residents and representatives within 24 hours of emergency transfer and that provision of appropriate notice be documented in the medical record.
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