Failure to Provide Bed-Hold Notice and Ombudsman Notification for Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to provide required written notification of its bed-hold policy and to notify the State Long Term Care Ombudsman when a resident was transferred to the hospital. The resident had multiple diagnoses including anemia, chronic kidney disease Stage 3, DM, HTN, and major depressive disorder, and required substantial assistance with ADLs, used a wheelchair with setup assistance, and was identified as a fall risk. The resident’s care plan included monitoring for changes in mental status, lethargy, fatigue, tremors, seizures, breathing difficulties, and monitoring labs and electrolytes related to renal insufficiency. On one occasion, a critical hemoglobin value of 6.1 g/dl was reported by the lab, and the provider instructed staff to send the resident to the emergency room, after which the resident left the facility by ambulance and later returned from the hospital with end stage renal disease and anemia. Record review showed the resident’s clinical record lacked evidence of a bed-hold notice or bed-hold policy documentation related to this facility-initiated transfer to the hospital, and the facility was unable to provide such evidence upon request. The facility also could not provide evidence that the State LTCO was notified of the resident’s transfer/discharge to the hospital. During an interview, a social services staff member confirmed that there was no bed-hold notice for the resident’s hospital transfer and that the Ombudsman had not been notified. The facility’s own bed-hold policy required staff to inform residents upon admission and prior to transfer for hospitalization (including after emergency transfers, per state law) about the bed-hold policy and to file a copy of the resident’s bed-hold policy in the medical record, but this was not documented for the resident. The facility was also unable to provide an Ombudsman Notification policy upon request.
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