Failure to Provide Bed Hold Policy Notification Upon Hospital Transfer
Penalty
Summary
The facility failed to provide written information regarding bed hold policies to a resident and their responsible party upon the resident's transfer to a General Acute Care Hospital (GACH). The resident, who had diagnoses including Type 2 Diabetes, COPD, and schizoaffective disorder, was transferred for psychiatric evaluation due to medication refusal, hostile behavior, and increased delusions. Documentation showed a physician's order for a seven-day bed hold, but there was no evidence that the resident or their responsible party received written notification about the bed hold policy at the time of transfer or within 24 hours, as required by facility policy. Interviews with the resident, the responsible party, and facility staff confirmed that neither the resident nor the responsible party was informed or provided with written information about the bed hold policy during or after the transfer. The Director of Nursing acknowledged that the facility's policy requires written notification upon admission and at the time of transfer, or within 24 hours in the case of an emergency, but there was no documentation that this occurred. The facility's policy and procedure for bed holds and returns, revised in 2022, was not followed in this instance.