Failure to Obtain Required Bed Hold Notice Signatures
Penalty
Summary
The facility failed to ensure that required bed hold notices were properly signed by the resident's representative when a resident with severe cognitive impairment was transferred out of the facility on two separate occasions. Clinical record review showed that the resident, who had diagnoses including hypertension, anemia, and arthritis, was hospitalized twice, and in both instances, the bed hold documentation only included verbal authorization from the resident's representative without obtaining the necessary signature. Facility policy requires that the Notice of Bed-Hold Policy be mailed if the family or representative does not come to the facility to receive a copy, but there was no evidence that this was done. Interviews confirmed that the signatures were missed and should have been obtained.