F0628

D

Failure to Provide Bed-Hold Notices and Proper Involuntary Discharge Procedures

Davenport, Iowa Survey Completed on 03-25-2026

Penalty

Fine: $10,225

Summary

Surveyors identified that the facility failed to provide required bed-hold notifications to a cognitively intact resident during two separate hospitalizations. Resident #3, who had a BIMS score of 14/15 indicating intact cognition, was admitted to the hospital twice and returned to the facility after each stay. Review of the electronic health record showed no documentation that a bed-hold notice or the facility’s bed-hold policy was issued to the resident for either hospitalization. The resident reported not remembering anyone discussing the bed-hold policy at admission or when he went to the hospital. The Administrator later confirmed by email that no bed holds were issued, despite a facility policy stating that a notice of transfer and the facility’s bed-hold policy would be provided to the resident and representative as part of emergency transfers to acute care.

Surveyors also found that the facility failed to properly execute transfer and discharge requirements for Resident #40, who had multiple diagnoses including diabetes mellitus, heart disease, kidney insufficiency, malnutrition, anxiety disorder, depression, osteomyelitis, difficulty walking, and used a manual wheelchair, with a BIMS score of 15/15 indicating intact cognition. The Ombudsman reported receiving phone messages from the resident stating he was being kicked out for allegedly pushing a pregnant staff member, which he denied, and that police had been notified, but the facility had not reported the incident, police action, or discharge. The Social Service Director stated she had been working since fall 2025 to find a community facility for the resident, that he had received discharge papers in February 2026, and that on the day of discharge she was instructed to give him discharge papers to a homeless shelter, including appeal paperwork, which he refused to sign. She acknowledged that the physician was not notified of the aggressive behavior and that she did not notify the LTC Ombudsman.

Review of two discharge letters on facility letterhead for Resident #40, dated in February and March 2026, showed notices of immediate involuntary discharge citing federal and state regulations, with an identified homeless shelter as the discharge destination and a statement that right-to-appeal information was included. Both notices were unsigned but indicated they were sent to the physician and Ombudsman. In interviews, the Administrator stated she discharged the resident due to potential for violence and aggressive behaviors, acknowledged that she did not notify the Department of Inspection, Appeals and Licensing or the LTC Ombudsman for either the 30‑day involuntary discharge notice or the emergent discharge, and stated she expected nursing to notify the physician. She also stated she was unsure what a recapitulation of stay entailed, despite facility policy requiring a physician’s order for transfer or discharge, documentation by a physician regarding the reason for transfer or discharge when safety is endangered, evidence that notice was sent to the Ombudsman, and completion of a discharge summary including a recap of the stay and a post‑discharge plan of care developed with resident participation.