Failure to Provide Required Written Transfer and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide required written notifications of transfer, discharge, and bed-hold rights to two residents and/or their representatives, and to send copies of such notifications to the ombudsman. One resident with dementia and anxiety had an unplanned discharge to the hospital for a right hip fracture, with progress notes documenting the hospital transfer and subsequent cancellation of a care plan meeting due to the hospitalization. However, the electronic record under the miscellaneous tab lacked evidence that written bed-hold documentation was provided to the resident or representative at the time of transfer. Staff interviews revealed confusion and inconsistency regarding responsibility for issuing bed-hold notices: nursing staff reported that social services handled bed-hold notices, social services and administrative staff identified a specific administrative staff member as responsible, and that staff member stated she completed bed-hold forms after being notified via the EHR dashboard and typically obtained signatures upon the resident’s return or by mailing the form days later. This practice conflicted with the facility’s own written bed-hold policy, which required written notice at admission and again at the time of transfer, with the charge nurse sending a blank notice with the resident at discharge and administration documenting attempts to contact the resident or representative within 24 hours. The deficiency also includes the facility’s failure to provide written notification of the reason for hospital transfers to another resident with dementia, Stage 2 skin breakdown, and CHF, who experienced multiple acute episodes requiring transfer to the hospital for pneumonia and other symptoms such as shortness of breath, chest pain, pallor, weakness, diaphoresis, brief unresponsiveness, drooling, and hypotension. Nursing notes documented the clinical events and physician orders to send the resident to the hospital, as well as the hospital admissions, but the electronic medical record lacked documentation of any written notification to the resident or representative explaining the reasons for these transfers. In interviews, social services staff stated that the business office manager obtained bed-hold signatures and acknowledged being unaware of the regulatory requirement to notify residents in writing of the reason for transfer, although they reported notifying the ombudsman of transfers. Administrative staff further stated that bed-hold forms should be completed and signed when a person was transferred out, but also stated that the facility did not notify residents’ representatives in writing of a discharge or transfer, and the administrative nurse reported that the facility did not have a discharge policy.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.