F0628

E

Failure to Provide Required Written Transfer/Discharge and Bed-Hold Notices

Edmonds, Washington Survey Completed on 03-04-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in the facility’s failure to provide required written transfer/discharge notices and bed-hold information to residents and/or their representatives in connection with multiple hospital transfers. The facility’s policy titled “Transfer or Discharge Notice,” revised in March 2021, required that residents and/or representatives be notified in writing, in a language and format they understand, including the specific reason for the transfer or discharge, the date, the receiving location, and an explanation of appeal rights. Record review for one resident showed a discharge MDS indicating admission and subsequent discharge to an acute hospital, with the EHR documenting discharge on a specific date but containing no evidence that a written transfer/discharge notice was provided. In interview, the Resident Care Manager stated that when a resident discharged to the hospital they would usually call the family and was unsure if a written notice was provided; the Executive Director confirmed that a written notice should have been provided and that there was no such documentation in the record.

For another resident, a quarterly/discharge MDS showed admission to a short-term general hospital, and the facility’s Transfer Form documented transfer to the hospital for abnormal lab results. However, the Transfer Form did not include a statement of the resident’s appeal rights or Ombudsman contact information as required, and the EHR contained no documentation that a written transfer/discharge notice was provided to the resident or representative. A third resident had multiple discharge MDS entries indicating admissions to a short-term general hospital, and several Transfer Forms documented transfers for chest pain, uncontrolled pain, and shortness of breath. None of these Transfer Forms contained the required appeal rights statement or Ombudsman contact information, and the EHR lacked documentation that a written transfer/discharge notice was provided. A fourth resident also had multiple discharge MDS entries for hospital admissions, with Transfer Forms documenting transfers for surgery, abnormal vital signs with no urine output from a nephrostomy, increased temperature and heart rate, suspected kidney infection, and unresponsiveness. Each of these Transfer Forms lacked the required appeal rights and Ombudsman information, and the EHR showed no documentation that a written transfer/discharge notice was provided.

Staff interviews further confirmed that the required written notices were not being provided. A registered nurse reported that when a resident was transferred to the hospital, they completed the transfer form/packet, made a copy for the resident, and verbally notified the resident or representative of the bed hold if the resident was alert, but did not reference providing written appeal rights or Ombudsman information. The Resident Care Manager stated they had never provided a transfer/discharge notice that informed residents or representatives of appeal rights and Ombudsman contact information and confirmed that the transfer form did not contain this information. The Executive Director acknowledged that the facility used the transfer form and that it did not include the required appeal rights and Ombudsman notification.

Surveyors also found a deficiency related to bed-hold notices. The facility’s “Bed-Holds and Returns” policy, revised in October 2022, required that all residents/representatives receive written information about facility and state bed-hold policies at least twice: in advance (e.g., in the admission packet) and again at the time of transfer or within 24 hours for emergency transfers. For one resident, a discharge MDS showed admission to a short-term general hospital, and the resident stated they were not notified of a bed hold. The resident’s Bed-Hold and Return Agreement in the record was undated and not completed, and there was no documentation in the EHR or progress notes that a bed-hold notice was provided. The Medical Records Director confirmed that the agreement was loaded but incomplete and that there was no progress note documenting provision of a bed-hold notice.

For another resident with a discharge MDS indicating admission to a short-term general hospital, the resident’s representative reported not being notified of a bed hold. Review of the EHR showed no documentation that a bed-hold notice was provided to the resident or representative. The Social Service Director stated that nursing would notify the resident of a bed hold and, if unable, the Business Office Manager would follow up with the representative and document at a minimum with a progress note. The Business Office Manager described a process of providing a bed-hold form, calling the representative, and documenting in progress notes, but acknowledged that no progress note was found indicating that a bed-hold notice was provided to these two residents or their representatives and stated that they should have been notified and it should have been documented. The Executive Director stated that the expectation was for staff to offer a bed-hold notice when a resident was discharged to the hospital and to follow up and document if they were unable to provide it at the time of transfer.