Failure to Document Bed Hold Choice and Ombudsman Notification
Penalty
Summary
The facility failed to obtain and document the resident or resident representative's choice regarding bed hold during a hospital transfer for one resident. Specifically, although the facility's policy requires that written information about the bed hold policy be provided and that the resident or representative be contacted to document their decision, the record for a resident with COPD and heart failure showed that while the bed hold policy was sent with the resident to the hospital, there was no documentation of any contact with the resident or representative to obtain their decision. The relevant form was incomplete, lacking both the resident or representative's choice and signatures, and there was no evidence of attempts to reach the representative. Additionally, the facility did not document notification to the Ombudsman regarding the discharge of another resident with COPD and hypertension. The facility administrator confirmed that there was no documentation reflecting that the Ombudsman was notified of the resident's discharge, as required. These findings were based on record review and staff interviews.