Failure to Provide Bed Hold Notice Upon Resident Transfer
Penalty
Summary
The facility failed to provide the required bed hold notice to a resident or the resident's responsible person when the resident was transferred out of the facility. According to the Minimum Data Set, the resident had no cognitive impairment and was transferred to the hospital due to shortness of breath, chest pain, and discomfort, with a request for hospital transfer. Documentation in the Electronic Health Record confirmed the resident's transfer and continued hospital stay, but there was no evidence that a bed hold notice was completed or communicated at the time of transfer. Interviews with the Director of Nursing (DON) and the Administrator confirmed that the bed hold form was not completed as required by both federal regulation and facility policy. The DON acknowledged the absence of documentation and stated that the expectation was for the bed hold to be completed or for the resident's representative to be notified, which did not occur. The facility's policy required residents or their representatives to verify their wish to hold the bed within 24 hours of hospital admission, but this process was not followed for the resident in question.