A facility failed to provide required written bed-hold and transfer notices to three residents and their representatives when the residents were sent to the ER by ambulance. The notices were not given before transfer or upon return and did not include the required reason, date, location, appeal rights, or Ombudsman contact information; family representatives said they were only called about the transfers and did not receive the forms by hand delivery or mail.
Failure to Provide Written Transfer and Bed Hold Notices: The facility did not provide written transfer notices to the representatives of two residents who were sent to the ED by EMS after acute events. One resident had Parkinson’s disease, repeated falls, and moderate cognitive impairment after a fractured femur was identified; the other had Alzheimer’s disease, dementia, anxiety, and severe cognitive impairment after a fall. Records contained no transfer or bed hold documentation, and staff could not confirm that the required written notices were mailed to the representatives.
A resident was transferred to the hospital without written notice of the transfer, the reason for the transfer, or the bed hold policy, and no copy of the notice was kept in the EMR. The record also lacked documentation of the transfer/discharge and the facility did not notify the State LTC Ombudsman. Staff interviews showed the facility relied on verbal notification and only provided transfer and bed hold forms if requested.
Failure to Provide Written Transfer/Discharge Notice: The facility did not provide a resident’s representative with written notice of hospital transfers or the reasons for the moves, and the record lacked Transfer/Discharge Notices for either event. The resident had cerebral palsy, malnutrition, and epilepsy, and was rarely or never understood per MDS. Staff stated the family was informed verbally, while the BOM handled bed-hold notices and was unsure who was responsible for the written transfer/discharge notice.
Failure to Provide Transfer Notices to Resident Representatives: The facility did not provide the required written transfer/bed-hold notice to the representatives of two residents who were sent to the hospital. One resident had severe cognitive impairment with dx including IDD, DM2, and epilepsy, and the other had moderate cognitive impairment with dx including pneumonia, subdural hemorrhage, and HTN. In both cases, the transfer forms had blank mailing documentation, and the representatives stated they never received the paperwork.
Failure to Notify Family of Hospital Transfer and Required Written Notice A resident with severe cognitive impairment and multiple chronic diagnoses was sent to the ER, but the facility did not notify the resident's representative or provide written notice of the transfer, the reason, location, or appeal rights. A grievance log noted the family was not notified, and interviews with the family member, MDS Coordinator, DON, and Administrator confirmed the representative was not called or given a bed-hold notice.
Failure to Provide Written Transfer and Bed-Hold Notices: A resident with hip fracture, Alzheimer's disease, and BPH was transferred to the hospital for hematuria, but the facility did not provide the resident's POA with a written transfer notice, appeal rights, state agency contact information, or a written bed-hold notice. The packet sent with the resident contained clinical information only, and the Administrator stated the facility called family but did not send written notice.
Failure to provide written transfer and bed hold notices: Two residents with intact cognition and significant medical histories, including dementia, CKD, and acute kidney failure, were transferred to the hospital, but the facility did not consistently notify the resident’s representative in writing of the bed hold notice, transfer/discharge, or reasons for the move in a language and manner they could understand. Staff interviews showed the BOM handled notices inconsistently, the DON said nursing did not complete the notifications, and the Administrator expected the notices to be sent and documented.
Failure to provide written transfer, discharge, and bed-hold notices: The facility did not give 3 residents and their representatives the required written notices for emergency transfers/discharges, including the reason for the move, transfer date and location, appeal rights, and LTC Ombudsman contact information. The EMR had no transfer/discharge or bed-hold notices for any of the residents, and family members reported they were only called and told verbally about the transfers.
Failure to provide bed hold notifications for two residents during emergent hospital transfers. The facility policy required a written bed hold notice to be given to the resident or representative within 24 hours of an emergency transfer, but there was no documentation in the EMR or paper chart for either resident, and the facility could not produce copies of the notices. Interviews showed inconsistent understanding among staff about whether the floor nurses or the business office were responsible, while the DON stated floor nurses were expected to ensure the resident or representative received the form.
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