Failure to Inform Residents of Bed-Hold Rights During Hospital Transfers
Penalty
Summary
The facility failed to inform residents and/or their representatives about their right to have their bed held during hospitalizations, as required by policy and regulation. Specifically, for two of four sampled residents reviewed for hospitalizations, there was no documentation that staff provided the necessary bed-hold notices at the time of, or shortly after, transfer to the hospital. The facility's policy required two notices: one at admission and another at the time of transfer or within 24 hours in emergencies, but these were not consistently provided or documented. For one resident with moderate cognitive impairment who was their own responsible party, there was no documentation of the reason for hospital transfer or evidence that the resident was informed of their bed-hold rights during two separate hospitalizations. Nursing progress notes and census records confirmed the absence of this required communication and documentation. Staff interviews further confirmed that the expected process of informing and documenting bed-hold rights was not followed in these instances. Another resident with severe cognitive impairment and significant behavioral issues was transferred to the hospital multiple times for various reasons, including falls and behavioral disturbances. Review of nursing and provider progress notes for each transfer revealed no documentation that the resident or their representative was informed of their right to hold their bed or that the bed-hold policy was reviewed at the time of transfer. Staff interviews corroborated that this information should have been provided and documented, but it was not.