Failure to Provide Required Bed-Hold Notices at Time of Hospital Transfers
Penalty
Summary
The deficiency involves the facility’s failure to provide required written bed-hold notifications to a resident at the time of multiple transfers to an acute care hospital, as required by its own Bed-Hold policy and federal and state guidelines. The resident was originally admitted and later readmitted to the facility, with diagnoses including seizures and conversion disorder with seizures. A History and Physical dated 12/2/2025 documented that the resident had the capacity to understand and make decisions, and a Minimum Data Set dated 12/4/2025 showed the resident required partial/moderate assistance with ADLs and certain mobility tasks. The facility’s Daily Census indicated the resident was on bed-hold on several dates when transferred out, and the Admission Coordinator stated the resident should have signed bed-hold notices for each of these transfers, in addition to the admission, with copies filed in the medical record. Record review and staff interviews confirmed that only one bed-hold agreement, signed on 12/1/2025, was present in the resident’s file, and there were no additional bed-hold notices for subsequent transfers. The facility’s Bed-Hold policy, dated 12/2016, required written notification of the bed-hold option upon admission and at the time of transfer to a hospital or therapeutic leave, specifying the duration of the bed-hold, sending a copy with the resident at transfer, and providing written notice to family or representative within 24 hours in case of emergency transfer. The LVN and Interim DON acknowledged that, according to this policy, residents who were transferred should receive written information about the option to exercise the bed-hold policy at each transfer, and that the absence of additional bed-hold notices in the resident’s file meant the facility did not follow its policy. The report states this failure had the potential for the resident not to exercise the option to use the facility’s bed-hold policy and lose their bed at the facility.
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