Failure to Provide Written Bed-Hold Policy Prior to Hospitalization
Penalty
Summary
The facility failed to provide written notification of its bed-hold and return policy to residents or their representatives prior to hospitalization, as required by its own policy. This deficiency was identified through record review and interviews, which revealed that four residents who were transferred to the hospital for various medical and behavioral reasons did not receive the required written documentation. The residents involved had complex medical and psychiatric diagnoses, including diabetes, schizoaffective disorder, bipolar disorder, PTSD, and intellectual disabilities. Each resident experienced an acute event necessitating hospital transfer, such as rib fractures with pneumothorax, abnormal diagnostic results, urinary tract infection, escalating aggressive behavior, or self-harm attempts. Despite multiple hospitalizations and clear documentation of the events leading to each transfer, there was no evidence in the residents' records that the facility provided the mandated written bed-hold and return policy prior to their departure. The facility administrator confirmed during the survey that the bed-hold forms were not being completed for residents transferred to the hospital, even though the facility's policy required this notification. The deficiency was found in all four cases reviewed for hospitalization in the sample.