Failure to Provide Written Bed Hold Policy and Notification During Resident Transfer
Penalty
Summary
The facility failed to provide a written bed hold policy and written notification regarding transfer for a resident who was hospitalized. The resident had diagnoses of acute hypoxia and respiratory failure, required oxygen and BiPAP, and was totally dependent on staff for transfers, toileting, and lower-body dressing. Documentation in the electronic health record showed that the resident's family requested a hospital transfer, but there was no evidence that a bed hold notice or written notification of the transfer was provided to the resident or their representative. Interviews with facility staff revealed inconsistent practices regarding the completion and communication of bed hold forms. Nursing and administrative staff reported that bed hold forms were sometimes completed verbally or sent after the transfer, and that the forms did not always include required information such as the cost of the room. The facility's own policy required written notice specifying the duration of the bed hold and details of the transfer to be provided at the time of transfer, but this was not followed in the case reviewed.