Failure to Provide Bed Hold Policy Notification Prior to Hospital Transfer
Penalty
Summary
The facility failed to provide required documentation or notification regarding the bed hold policy to two residents prior to their discharge to the hospital. Resident 35, who had diagnoses including kidney failure, respiratory failure, and pneumonitis due to inhalation of food and vomit, was sent to the hospital without any documentation in the medical record indicating that the bed hold policy had been explained to her or her family. Similarly, Resident 47, with diagnoses of respiratory failure, dysphagia, and altered mental status, was also transferred to the hospital without evidence that the bed hold policy was communicated to him or his family. The Director of Nursing confirmed that the bed hold policy should have been documented in the progress notes and that residents or their representatives should always be informed of the policy prior to leaving the facility. The facility's current policy requires informing residents upon admission and prior to transfer for hospitalization or therapeutic leave about the bed hold policy, but there was no documentation to show this occurred for the two residents.