Failure to Provide Bed-Hold Policy Notification at Hospital Transfer
Penalty
Summary
The facility failed to provide written notice of its bed-hold policy to residents and/or their representatives at the time of transfer to the hospital for five of six residents reviewed. Federal regulation S483.15(d) requires that residents receive written information about bed-hold policies both prior to and upon transfer, with documentation of attempts to notify representatives if direct notification is not possible. The facility's own policy also states that this information should be provided upon admission, transfer, or therapeutic leave, and if any changes occur to the policy. Clinical record reviews for multiple residents revealed that, despite being transferred to the hospital for various acute medical needs—including exacerbation of UTI symptoms, abnormal vital signs, fever, chest pain, and complications related to dialysis—there was no documentation that the required written bed-hold notification was given at the time of transfer. This deficiency was identified for residents with significant medical histories, such as coronary artery disease, diabetes, stroke, heart failure, seizure disorder, cardiomyopathy, chronic kidney disease, pneumonia, atrial fibrillation, hemiplegia, and malnutrition. During staff interviews, both the Nursing Home Administrator and the Director of Nursing confirmed that the facility did not ensure the provision of written bed-hold policy notices to residents or their representatives at the time of hospital transfer. This failure was observed across multiple instances and residents, as evidenced by the absence of documentation in the clinical records reviewed.