Failure to Provide Bed Hold Policy Documentation Prior to Resident Discharge
Penalty
Summary
The facility failed to provide required bed hold policy documentation and notification prior to the discharge or transfer of three residents. For each resident reviewed, there was no evidence in the medical record or discharge packet that the bed hold policy was explained or provided to the resident or their representative before transfer to the hospital. Specifically, discharge packets were either missing, incomplete, or left unsigned and undated, and progress notes did not mention any discussion or provision of the bed hold policy. In one case, the facility was unable to provide any documentation for a discharge event, and in another, the administrator confirmed that no bed hold policy was available for the date in question. The residents involved had significant medical conditions, including stroke, heart failure, seizures, diabetes, respiratory disease, and dementia. Despite the facility's policy stating that the bed hold notice and policy should be issued at the time of transfer or within 24 hours, there was no documentation to show that this requirement was met for any of the three residents. Interviews with the administrator revealed a lack of awareness regarding the need for documented proof of bed hold policy notification prior to discharge.