Failure to Document Provision of Bed Hold Policy Upon Hospital Transfer
Penalty
Summary
The facility failed to document that the bed hold policy was provided to a resident or their representative upon transfer to a local hospital. Specifically, for one resident with diagnoses including bipolar disorder and suicidal ideation, there was no documentation in the electronic medical record indicating that the bed hold notification was given when the resident was transferred to the hospital via 911 with an involuntary petition. Interviews with facility staff, including the administrator, DON, and Assistant DON, confirmed that the expectation is for the bed hold policy to be provided and documented at the time of transfer, but in this case, documentation was missing. Additionally, another resident with a history of bipolar disorder, diabetes type 2, alcohol dependence, and hypertension reported not receiving a copy of the bed hold policy or being informed about the 10-day bed hold policy when transferred to the hospital for emergency services. The facility's policy and resident handbook both state that residents are to be informed of the bed hold policy before and upon transfer to a hospital. Staff interviews acknowledged that the process was not followed consistently, and documentation was not completed as required.