Failure to Provide Bed Hold Notification at Time of Hospital Transfer
Penalty
Summary
The facility failed to provide written notice of bed hold at the time of transfer to the hospital for two residents who were reviewed for hospitalization. For one resident with Parkinsonism, diabetes, heart failure, and severely impaired cognition, the medical record indicated a decline in responsiveness and refusal of medication, leading to a provider-ordered hospital transfer. There was no documentation that a bed hold notification was given at the time of this transfer. For another resident with quadriplegia, depression, and chronic pain, who required total assistance for all activities of daily living and was cognitively intact, the record showed the resident was transferred to the hospital due to swelling and pain in both lower legs. Again, there was no documentation of a bed hold notification at the time of transfer. Interviews with facility staff confirmed that the required bed hold notifications were not completed or documented at the time of transfer for both residents. Staff acknowledged that the process involves speaking with the resident or their representative and obtaining a signature, but in these cases, the notifications were missed. The facility's standard requires a 24-hour follow-up with documentation in the nursing progress note, which was not observed in the records reviewed.