Failure to Honor Bed Hold Policy for Hospitalized Resident
Penalty
Summary
The facility failed to follow its own bed hold policy for a resident who was transferred to a general acute care hospital (GACH) due to tachycardia and hypertension. The resident, who had significant medical needs including respiratory failure, ventilator dependence, and a persistent vegetative state, had a signed bed hold consent indicating a 7-day bed hold was requested and confirmed. Facility records and staff interviews confirmed that the resident's bed was held for only three days before being assigned to a new resident, despite a physician's order and facility policy requiring a 7-day hold. When the hospital notified the facility that the resident was ready for return within the 7-day period, staff reported that the bed was no longer available, as it had already been given to another resident. This resulted in the resident being unable to return to the facility as planned and remaining in the hospital for additional days. Facility staff, including the administrator, acknowledged that the bed should have been reserved for the full 7 days as per policy and the signed consent.