Failure to Provide Bed Hold Notice Upon Hospital Discharge
Penalty
Summary
The facility failed to provide or offer a Bed Hold notice to a resident or the resident's representative upon discharge to the hospital, as required by facility policy and regulatory standards. Clinical record review showed that the resident, who had severe cognitive impairment and multiple complex medical diagnoses including pneumonia, viral hepatitis, wound infection, stroke, seizure disorder, traumatic brain injury, and respiratory failure, was discharged to the hospital on three separate occasions. There was no documentation in the clinical record that a Bed Hold notice was given during any of these hospitalizations. Interviews with the Administrator confirmed that the required Bed Hold documentation could not be located and that the resident's representative had not received the notice. Facility policy directed that Bed Hold information should be provided upon admission and at the time of transfer, including emergency transfers, and a copy should be filed in the resident's medical record. Despite these requirements, the necessary documentation and notification were not completed for this resident.