Failure to Provide Bed Hold Policy Notification During Hospital Transfers
Penalty
Summary
A deficiency was identified when the facility failed to provide required written notification of the bed hold policy to a resident and/or their representative at the time of transfer to the hospital. The resident, who had a history of seizure disorder, chronic lower back pain, and dementia, was hospitalized on three separate occasions. Review of the clinical record and facility documentation revealed no evidence that the bed hold policy, specifying the duration and terms, was given to the resident or their representative during any of these hospital transfers. Interviews with facility staff, including the DNS, social worker, and Chief Clinical Officer, confirmed that the process for providing and documenting the bed hold policy was not consistently followed. Staff were either unsure of their responsibilities or acknowledged that the policy was not being provided or documented as required. Facility policies reviewed indicated that notification of the bed hold policy should be given upon admission and in advance of any transfer, but there was no documentation to support that this occurred for the resident's hospitalizations.