Failure to Provide Required Written Transfer, Appeal, and Bed-Hold Notices
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide required written transfer, discharge, appeal rights, and bed-hold notifications to residents and their representatives, and to notify the Ombudsman, for residents who were transferred to the hospital. The facility’s Transfer and Discharge policy dated 06/11/25 required complete documentation, physician involvement, written notice to residents and/or representatives in a language and manner they understand, information on appeal rights, and notification of the Ombudsman. For one resident, admitted on an unspecified date, progress notes showed he was sent to the hospital on a specified date due to abnormal lab values, cancer treatment, PEG tube feeding, being bedbound, and a positive COVID test. However, his medical record contained no documented transfer notice or bed-hold notification related to this hospital transfer. For a second resident, admitted on an unspecified date, progress notes documented that he was sent to the hospital due to behavioral symptoms including agitation and psychosis, and later transferred to a psychiatric hospital after a hospital psychiatrist determined he was not safe to return. Review of this resident’s medical record likewise showed no documented transfer notice or bed-hold notification for the hospital transfer. In interviews, the Social Service Director stated there were no notes in the first resident’s record explaining why he did not return, acknowledged she did not contact the Ombudsman regarding his discharge, and confirmed there were no nurses’ notes regarding transfer, discharge, or bed-hold notices for either resident. She also stated she has not notified the Ombudsman of discharges in a while. The DON stated she did not realize nursing was responsible for the transfer and bed-hold notice process, although her expectation was that nurses and the business office send out transfer, discharge, and bed-hold notices within 24 hours.
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.