Failure to Provide and Document Bed Hold Notice During Hospital Transfer
Penalty
Summary
The facility failed to provide a written bed hold notice to the resident's representative when the resident was transferred to the hospital, and did not document any follow-up communication or attempts in the resident's medical record. The resident, who had dementia and severe cognitive impairment, was transferred to the hospital for a femoral neck fracture requiring surgery. Interviews with facility staff revealed inconsistent practices regarding the distribution and documentation of bed hold notices, with some staff stating that the notice is sent with the resident and others indicating that follow-up calls are made to the responsible party. However, there was no evidence in the resident's chart of a bed hold notice being provided or any follow-up attempts documented. The facility's own policy requires that upon a resident's transfer for hospitalization, written notice specifying the bed hold policy must be provided to the resident and their representative, and that attempts to contact the representative and their decision regarding the bed hold must be documented in the resident's record. In this case, the responsible party reported not being informed about the bed hold policy at the time of transfer, and the facility was unable to provide documentation that the required notice or follow-up occurred. This resulted in the potential for the resident and/or their representative to be uninformed about the bed hold policy during the hospital transfer.