Failure to Provide Required Written Transfer Notices and Bed-Hold Information
Penalty
Summary
Surveyors determined that the facility failed to provide required written notices related to hospital transfers and bed-hold policies for multiple residents. Review of the facility’s Discharge Planning Policy, last reviewed February 3, 2026, did not include the requirement to provide written notice of a transfer to the resident, the resident’s representative, or a representative of the Office of the State Long-Term Care Ombudsman. The Bed Hold Letter Policy, dated March 24, 2025, described internal tracking and notification processes for Medicaid bed-hold days but did not demonstrate that residents or their representatives actually received written bed-hold information at the time of transfer. Staff interviews with the DON, the Regional Director of Clinical Services, and the Nursing Home Administrator confirmed that no additional documentation could be produced to show that these notices were provided. Record review showed that one resident with muscle weakness, dysphagia, and delusional disorders was transferred to the hospital and there was no documentation that a written copy of the facility’s bed-hold policy was provided to the resident or representative. Another resident with dementia and atrial flutter was transferred to the hospital without documented written notice of the transfer or the facility’s bed-hold policy, and the facility’s Ombudsman reporting records for that month did not include this resident. A third resident with a fractured pelvis, spinal stenosis, COPD, and Medicaid as the payor source was transferred to the hospital and later returned, but the clinical record lacked evidence of written notice of the transfer, written notice of the bed-hold policy, or notification to the Ombudsman. The Nursing Home Administrator acknowledged that the facility did not have proof that these required notices and notifications were provided.
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