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F0628
D

Failure to Provide Bed Hold Notice Upon Resident Transfer

Torrance, California Survey Completed on 07-24-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide a written bed hold notice to the responsible party of a resident who was transferred to a general acute care hospital. Record review showed that the resident, who had severe cognitive impairment and was dependent in activities of daily living due to diagnoses including Huntington's disease, major depressive disorder, and dementia, was transferred for further assessment. There was no documented evidence in the medical record that a written bed hold notice or transfer agreement form was created or provided within 24 hours of the transfer. Interviews with facility staff, including an LVN, the Medical Records Supervisor, and the Director of Nursing, confirmed that the required bed hold and transfer forms were not completed at the time of the resident's transfer. Staff acknowledged that these forms are necessary to inform the resident or their representative of the bed hold policy and their rights, and that the facility's policy requires written notification prior to transfers. The absence of this documentation resulted in incomplete communication regarding the resident's bed hold status.

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