Failure to Provide Bed Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to provide required bed hold notices to residents and their representatives when residents were transferred to the hospital. For two residents reviewed, both with significant cognitive impairments and complex medical histories including diabetes, heart failure, and atrial fibrillation, there was no documentation in the medical records that a bed hold notice was given at the time of their hospital transfers. Nursing notes confirmed the residents were sent to the hospital for evaluation and treatment following changes in condition, and subsequently readmitted to the facility, but no evidence of bed hold notification was found. Interviews with facility staff revealed that the charge nurse did not provide bed hold notices, believing it was the responsibility of the admission coordinator. The admission coordinator confirmed that bed hold notices were not sent with residents upon hospital transfer and stated that she would only contact the resident's representative if there was a shortage of beds, but did not provide written notification. The administrator acknowledged that bed hold notices should be provided to all residents and their representatives when hospitalized, but this was not done in these cases.