Failure to Provide Bed-Hold and Transfer Notifications
Penalty
Summary
The facility failed to provide required written notices regarding bed-hold policies and transfer notifications to residents or their representatives during hospital transfers. Specifically, for two residents reviewed, there was no documentation in the medical records of bed-hold notifications or notices of transfer at the time of their hospitalizations. Staff interviews confirmed that the designated personnel did not notify the residents or their representatives about the bed-hold policy, and the expected documentation was missing from the residents' charts. Staff members provided inconsistent accounts of who was responsible for offering and documenting the bed-hold policy, with some stating that nurses or the business office manager should handle notifications, while others indicated that the admissions director provided initial education at admission only. One resident, who was alert, oriented, and required substantial assistance with activities of daily living, was transferred to the hospital and did not return, with no evidence of bed-hold notification or transfer notice in the record. Another resident, with multiple hospital transfers due to respiratory issues and a history of emphysema, anxiety, and bipolar disorder, reported not being aware of the bed-hold policy and had no documentation of such notifications during several hospitalizations. Staff interviews further revealed a lack of clarity and follow-through regarding the process for offering and documenting bed-hold notifications and transfer notices.