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F0625
D

Failure to Provide Written Bed Hold Policy Notification Upon Hospital Transfer

Silver Spring, Maryland Survey Completed on 04-16-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide written notification of its bed hold policy to a resident or the resident’s representative when the resident was transferred to an acute care hospital. Medical record review for the resident, who was receiving long-term care and was transferred to the hospital due to a change in condition, did not contain documentation that the bed hold policy was offered or provided at the time of transfer. The facility’s policy requires staff involved in the transfer, such as nursing, admissions, or social services, to provide the bed hold notice and authorization form to the resident and/or representative. Staff interviews revealed inconsistent practices regarding the provision of the bed hold policy. An LPN stated that the policy may not always be offered when residents are sent to the hospital, especially in urgent situations. An RN reported that the policy is typically communicated and distributed, with copies sent to the hospital, business office, and the resident’s family. However, when asked to produce documentation for this specific transfer, the RN was unable to locate any evidence in the medical record or elsewhere that the bed hold policy had been provided to the resident or their representative.

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