Failure to Provide Written Bed Hold Notice and Reason for Transfer
Penalty
Summary
The facility failed to provide a written bed hold notice or reason for transfer to a resident at the time of two separate hospital transfers. According to the facility's own policies, written information regarding bed hold practices and the reason for transfer must be given to the resident and/or their representative both in advance and at the time of transfer. Review of the clinical record for the resident, who had diagnoses including acute kidney failure and paroxysmal atrial fibrillation and demonstrated little to no cognitive impairment, showed no evidence that such documentation was provided during transfers to the hospital on two occasions. Interviews with the resident, their representative, and facility staff confirmed that neither a written bed hold notice nor a reason for transfer was given at the time of either hospital transfer. Nursing staff reported that they did not issue bed hold notifications, stating that this responsibility fell to administration, while the administrator was unable to produce any proof that the required documentation had been provided. The absence of these notifications was corroborated by both the resident and their representative.