Failure to Provide Bed Hold Policy Documentation at Hospital Transfer
Penalty
Summary
The facility failed to provide required bed hold policy documentation to residents or their representatives at the time of transfer to the hospital for four residents reviewed. Each resident had significant medical conditions, including paraplegia, neuromuscular dysfunction of the bladder, dementia, subdural hemorrhage, Parkinson's disease, chronic obstructive pulmonary disease, infection related to a joint prosthesis, cerebral infarction, and convulsions. In each case, the clinical records and progress notes documented the residents' acute changes in condition and subsequent transfers to the hospital, but lacked evidence that the bed hold policy was given to the resident or their representative at the time of discharge. Interviews and record reviews confirmed that the required bed hold notifications were not documented as provided during these transfers, even when family members were present or involved in the decision to send the resident to the hospital. The Director of Nursing acknowledged awareness of the requirement but indicated that in emergent situations, the process may not be completed. The facility's written policy requires that bed hold information be provided at the time of transfer, but this was not reflected in the clinical records for the residents reviewed.