Failure to Maintain Required Bed Hold and Notification for Hospitalized Residents
Penalty
Summary
The facility failed to maintain a seven-day bed hold for two residents who were transferred to a General Acute Care Hospital (GACH), resulting in a violation of their rights to return to their assigned beds. For one resident with severe cognitive impairment and multiple diagnoses, the bed was assigned to another individual just one day after transfer, despite the requirement to hold the bed for seven days. Staff interviews confirmed that the bed hold was not honored, and there was no clear explanation for this action. The resident's need for continuity and comfort in returning to the same room was acknowledged by staff, but not upheld in practice. For another resident, also with severe cognitive impairment and significant medical conditions, the bed hold process was not properly followed. Although the resident was placed on bed hold status, the bed was not available upon readmission, and the resident was placed in a different bed. Additionally, the required Bed Hold Informed Consent form was not completed, meaning the responsible party was not properly informed of the resident's rights. Facility policy requires written notification of bed hold rights prior to transfer, but this was not consistently implemented, leading to the deficiency.