Failure to Provide Written Bed Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to provide written notice of bed hold rights to four sampled residents or their responsible parties at the time of transfer to an acute care hospital. In each case, interviews and record reviews confirmed that neither the residents nor their responsible parties received the required written notification regarding the option to request a bed hold during hospitalization or therapeutic leave. Instead, notifications were either given verbally or not at all, and there was no documentation in the electronic health records to indicate that written notices had been provided. The residents involved had various medical conditions, including encephalopathy, urinary tract infection, femoral neck fracture, congestive heart failure, hypertensive heart disease, and acute bronchitis. Responsible parties for these residents reported not receiving any written bed hold notices and were unaware of their rights regarding bed holds and the possibility of returning to the facility after hospitalization. Facility staff interviews further confirmed the absence of written notifications and revealed that the process for providing such notices was inconsistent and not documented as required by facility policy.