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F0628
E

Failure to Provide Written Bed-Hold Notification and Rate at Time of Transfer

Muskego, Wisconsin Survey Completed on 06-16-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide written notification of transfer/discharge, bed-hold policies, and the specific daily rate for bed-hold to four residents and/or their representatives at the time of transfer to the hospital. In each case, the facility's process involved obtaining verbal consent for bed-hold from the resident or their representative, but did not include providing the required written documentation as outlined in the facility's own policy. The documentation reviewed by the surveyor consistently lacked the specific daily rate for holding the bed, and written notices were not given to the residents or their representatives at the time of transfer. For example, one resident with multiple diagnoses including dementia, atrial fibrillation, and diabetes was transferred to the hospital on two separate occasions. In both instances, the transfer, bed-hold notice, and readmission rights forms were completed after the transfer, with only verbal consent documented and no written notice or specific daily rate provided. Another resident with dementia and heart failure was transferred following a fall, and the resident's power of attorney was notified verbally, but again, no written notice or bed-hold rate was provided. Interviews with staff confirmed that the process relied on verbal communication and that written notices were not routinely sent to residents or their representatives. Additional cases included a resident with myelodysplastic syndrome and another with chronic obstructive pulmonary disease, both of whom were transferred to the hospital. In these cases, the bed-hold forms in the medical records did not specify the daily rate, and staff interviews revealed that the rate was only provided at admission, not at the time of transfer. The surveyor confirmed with the nursing home administrator that the daily rate was not included on the transfer documents, and that written notification was not provided as required.

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