Failure to Provide Timely Bed Hold Policy and Transfer Notification
Penalty
Summary
The facility failed to provide written bed hold policies and timely written notifications of transfers for three residents who were hospitalized. Review of the electronic health records (EHR) for these residents showed no evidence that bed hold notices or written notifications of transfer were provided to the residents or their representatives at the time of transfer. Specifically, one resident was transferred to the hospital on multiple occasions without documentation of the required notifications, and another resident's transfer lacked a signed bed hold form for one of the hospitalizations. Staff interviews revealed that, in practice, bed hold forms were sometimes sent unsigned with residents during emergency transfers, and follow-up for signatures was handled later, with forms kept in a separate folder rather than uploaded to the EHR. The facility's policy required informing residents of the bed hold policy upon admission and prior to transfer, including any charges and Medicaid time limits. However, the process described by staff did not consistently ensure that residents or their representatives received or signed the bed hold forms at the time of transfer, particularly during emergencies. Additionally, the required information was not always documented in the EHR as expected by facility leadership, resulting in incomplete records of notification and policy provision.