Failure to Provide Bed Hold Notice and Required Transfer Documentation
Penalty
Summary
The facility failed to provide a written bed hold notice to a resident or the resident’s representative prior to the resident’s transfer to the hospital. Medical record review showed no documentation that a bed hold notice was given, nor was there evidence that the required care plan goals or specific transfer information were sent to the hospital at the time of transfer. Interviews with facility staff, including the DON and hospital liaison, confirmed that the resident was transferred due to behavioral issues without being seen by facility psychiatric services or a facility physician, and that no paperwork or belongings accompanied the resident to the hospital. Further interviews with hospital social workers revealed that the hospital did not receive any paperwork or a bed hold notice for the resident upon transfer. The DON acknowledged making the decision to send the resident back to the hospital and confirmed that the resident was not under involuntary discharge. The facility hospital liaison and medical director also confirmed a lack of involvement in the transfer decision and absence of required documentation, resulting in the deficiency.