Failure to Provide Required Written Transfer and Bed-Hold Notifications
Penalty
Summary
Surveyors identified a failure to provide required written notification of transfer for a resident who was hospitalized. The resident had diagnoses including obesity, dependence on supplemental oxygen, cognitive communication deficit, and skin cancer. On 12/11/25, nursing notes documented the resident was short of breath, coughing up yellow sputum, and had an oxygen saturation of 88%, leading to new medication, lab orders, and a mobile chest X-ray. Later that day, a nurse documented leaving a message for the responsible party that the resident was going to the hospital, and that the resident left with emergency services. The resident returned to the facility on 12/22/25 and was to receive skilled therapy services. The EMR contained a bed-hold assessment with verbal confirmation but lacked documentation of written notification to the resident and/or representative explaining the reason for the transfer to the hospital. During interviews, the resident stated he was supposed to sign the bed hold but was not given it before leaving for the hospital. Social Service staff reported that one social worker obtained bed holds when a resident left, but they were not aware of or unsure about sending written letters to residents or representatives or notifying the ombudsman. Administrative nursing staff confirmed the facility had not been sending written notifications to families with the reason for transfer, nor sending notifications to the ombudsman, noting that an email had been sent one month prior but not since. This practice was inconsistent with the facility’s Transfer and Discharge policy, which requires that a transfer/discharge notice be provided to the resident and representative, including the specific reason for transfer, effective date, destination, appeal rights and procedures, and contact information for the state appeal entity, ombudsman, and protection and advocacy agencies where applicable.
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