Failure to Provide Bed Hold Notice Prior to Hospital Transfer
Penalty
Summary
The facility failed to provide a required bed hold notice to a resident and/or the resident's responsible party prior to the resident's transfer to a general acute care hospital. The resident, who had a history of cognitive impairment, dependence on staff for activities of daily living, and multiple medical and psychiatric diagnoses, was transferred under a physician's order for a 72-hour mental health evaluation. Upon review of the resident's records, there was no documented evidence that the resident or their representative was informed about the facility's bed hold policy at the time of transfer. Interviews with facility staff, including a registered nurse and the director of nursing, confirmed that no bed hold notice was provided and that there was uncertainty regarding the need for a physician's order for a bed hold. The facility's own policy required written notification to the resident or their representative about the bed hold policy prior to transfer, but this was not followed in this instance.