Failure to Provide Written Bed-Hold Policy Notice at Time of Hospital Transfer
Penalty
Summary
The facility failed to provide written notice specifying the duration of the bed-hold policy to residents or their responsible parties at the time of transfer to a hospital or rehabilitation facility for two out of three sampled residents. According to the facility's own policy, written information regarding bed-hold practices must be given both at admission and at the time of transfer for hospitalization or therapeutic leave. However, record reviews and interviews confirmed that there was no documented evidence that such notice was provided to the affected residents or their representatives during their transfers. One resident, admitted with conditions including unsteadiness, morbid obesity, and a need for assistance with personal care, was transferred to a rehabilitation hospital and confirmed in an interview that no written bed-hold information was provided or signed prior to transfer. Another resident, admitted with a displaced bimalleolar fracture and gait abnormalities, was transferred to a local hospital for surgery, and again, no documentation or confirmation of written bed-hold notice was found. Facility staff, including the DON and administrator, acknowledged the absence of required documentation for both residents at the time of their transfers.