Failure to Provide Written Bed-Hold Policy Notification at Time of Hospital Transfer
Penalty
Summary
The facility failed to provide written notice of its bed-hold policy to residents or their representatives at the time of transfer to the hospital for five out of nine residents reviewed. According to the facility's own policy, written notification of the bed-hold policy is required for all residents at the time of transfer, regardless of payer source. Clinical record reviews for multiple residents revealed no documentation that this notification was given during several hospital transfers. These residents had various medical conditions, including cerebral palsy, paraplegia, seizure disorder, coronary artery disease, history of stroke, chronic kidney disease, diabetes, heart failure, and psychotic disorder. Transfers occurred for reasons such as high fever, hypertensive crisis, low oxygen levels, erratic behavior, hallucinations, low blood sugar, pain, and other acute symptoms. Staff interviews with the Nursing Home Administrator and the DON confirmed that the facility did not ensure written notice of the bed-hold policy was provided at the time of transfer for the affected residents. The deficiency was identified through policy review, clinical record review, and staff interviews, with no evidence found in the records that the required notifications were given during any of the documented transfers for these residents.