Failure to Document Hospital Transfer, Notifications, and Bed Hold Notice
Penalty
Summary
The facility failed to document a resident's transfer to the hospital, including the required notifications to the physician and family, and did not provide documentation of a bed hold notice for one resident. Clinical record review showed that the resident, who had diagnoses of non-Alzheimer's dementia, stroke, and heart failure and was severely cognitively impaired, was on hospital leave for over two weeks. However, the resident's progress notes during this period lacked documentation of the transfer event, notifications to the physician and family, and completion of a bed hold notice. Further review of facility policy indicated that staff are required to obtain a physician's order for emergency transfers, provide necessary information to the receiving provider, document assessment findings and relevant information in the medical record, and provide a notice of transfer and bed hold policy to the resident and their representative. The Corporate Nurse confirmed that there was no documentation in the electronic health record regarding the assessment prior to transfer, bed hold notice, transfer information, or notifications to the physician and family, which was not in accordance with facility expectations.