Failure to Provide and Document Bed Hold Notices During Resident Transfers
Penalty
Summary
The facility failed to ensure that bed hold notices were provided to and signed by residents or their representatives when residents were transferred out of the facility, as required by facility policy. Clinical record reviews and staff interviews revealed that for four residents who experienced hospitalizations or transfers, there was no documentation of bed hold notifications in their medical records. Specifically, the records for these residents lacked bed hold forms for multiple hospital stays, and staff confirmed that the required notifications were not completed at the time of transfer. The residents involved had various medical conditions, including severe cognitive impairment, stroke, aphasia, hypertension, depression, acute respiratory failure, anemia, cancer, and malnutrition. In each case, the residents were transferred to the hospital for acute medical issues such as fractures, infections, or respiratory problems. Despite these transfers, the facility did not provide or document the required written bed hold notifications, as confirmed by the Director of Nursing, Assistant Director of Nursing, and Medical Records staff during interviews.