Failure to Provide Bed Hold Policy Notification During Hospital Transfers
Penalty
Summary
The facility failed to inform two cognitively intact residents of the Bed Hold Policy when they were transferred to the hospital. For one resident with Type 2 diabetes mellitus, staff responded to a medical emergency involving a fall and low blood glucose, resulting in the resident being transported to the hospital by EMS. There was no documentation that the resident or their representative received a copy of the Bed Hold Policy or written notice of transfer, as required by facility policy. Staff interviews confirmed that the process was not followed, with some staff stating that only verbal offers were made or that paperwork was not provided at the time of transfer. A second resident, admitted with acute kidney disease, was also transferred to the hospital after developing severe symptoms, including blisters and pain. Review of the clinical record found no documentation that the resident was informed of the Bed Hold Policy or received written notice of transfer. Facility leadership confirmed that the required notices were not given in either case, and staff acknowledged the oversight in providing discharge and treatment notices.