Failure to Provide Bed Hold Policy Notification on Resident Transfer
Penalty
Summary
The facility failed to provide the required bed hold policy notification to the responsible representative when a resident was transferred out to the hospital. Medical record review showed that the resident had multiple hospital transfers, with the most recent involving a fall and subsequent transfer via 911. While the resident had acknowledged receipt of the bed hold policy upon admission, there was no evidence that a copy was provided or mailed to the responsible representative at the time of the most recent transfer. Staff interviews revealed inconsistencies and lack of awareness regarding the process for distributing the bed hold policy during transfers. One nurse was unfamiliar with the bed hold policy, while another stated the policy was given to the resident but was unsure if it was sent to the responsible representative. The Admissions Director indicated that nursing was responsible for this task, but also confirmed that only the admission acknowledgment was on file. The DON was not aware of the requirement to mail the policy to the responsible representative upon transfer.