Failure to Provide Bed-Hold Notices Upon Resident Transfer
Penalty
Summary
Facility staff failed to provide written bed-hold notices to residents and/or their representatives upon transfer to a hospital or for therapeutic leave, as required by facility policy. In multiple instances, surveyors found no evidence in the clinical records that the bed-hold policy was given at the time of transfer, despite requests for documentation. The facility's own policy, reviewed and revised on 12/1/22, states that written notice specifying the duration of the bed-hold policy must be provided at the time of transfer for hospitalization. Specific cases included residents with significant medical histories and varying cognitive abilities. One resident with severe cognitive impairment and multiple diagnoses, including cerebral infarction and acute respiratory failure, was transferred to the hospital without documentation of a bed-hold notice being provided. Another resident, cognitively intact and diagnosed with hemiplegia, diabetes, and other conditions, was also transferred without evidence of receiving the required notice. Additional residents with complex medical backgrounds, including dementia, chronic kidney disease, and depression, were similarly affected. Staff interviews and record reviews confirmed that in each case, no documentation could be found to show that the bed-hold policy was communicated to the resident or their representative at the time of transfer. The issue was discussed with facility leadership during survey meetings, and the only documentation provided was the facility's policy itself, not evidence of compliance for the affected residents.