Failure to Provide Written Bed-Hold Notification During Hospital Transfer
Penalty
Summary
The facility failed to provide written notification to a resident and their responsible party regarding the reason for transfer/discharge to the hospital, as well as information about bed-hold policies. The resident involved had diagnoses including GERD without bleeding, gastrostomy status, dysphagia, and cerebral infarction, and was assessed as having moderate cognitive difficulty. Following an incident where the resident vomited a large amount of dark black emesis, the provider and responsible party were notified, and the resident was sent to the hospital. However, there was no documentation in the clinical record indicating that the resident or responsible party was informed in writing about the bed-hold options at the time of transfer. Interviews with facility staff, including the ADNS, Administrator, and Business Office Manager, revealed a lack of clarity and process regarding written notification of bed-hold policies upon hospital transfer. The ADNS was unaware of the process, and the Administrator could not demonstrate how written notification was provided at the time of transfer. Although bed-hold information was included in the admission packet, there was no evidence of a specific form or documentation used to track or confirm that this information was provided in writing during the transfer event, as required by facility policy.