Failure to Provide Proper Bed Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to provide written bed hold notices to residents or their representatives at the time of transfer to the hospital for three of four sampled residents reviewed for hospitalization. For one resident, documentation showed that the bed hold notice was signed by a staff member, but there was no time recorded, and the section for the resident or representative was marked as 'refused' without specifying who refused or the date and time of contact. Another resident, who was cognitively intact, denied being offered a bed hold notice, and their family member confirmed not being contacted. Staff interviews revealed a lack of understanding of the bed hold policy, with some staff unaware of the requirement and others indicating that they would mark 'refused' if unable to reach the resident or representative, without documenting attempts or details of contact. For a third resident, who was cognitively impaired, multiple hospital transfers were documented, but there was no evidence that the representative was provided with written information about the bed hold policy or their decisions. Bed hold notices for this resident were signed by staff, with 'refused' written in the resident or representative section, again without documentation of who refused or when contact was attempted. Staff confirmed that they did not document the details of their attempts to contact representatives and acknowledged that the documentation should have reflected unsuccessful contact attempts rather than refusals.