F0628

D

Failure to Provide Written Transfer Notice and Bed-Hold Policy at Hospitalization

Battle Creek, Michigan Survey Completed on 01-22-2026

Penalty

No penalty information released

Summary

The facility failed to provide required written notification of transfer and bed-hold policy to a resident and/or the resident’s representative at the time of a hospital transfer. The resident was an older male with diagnoses including a progressive neurologic disorder, dementia with agitation, and an adjustment disorder with anxiety. His MDS showed a BIM score of 9, indicating moderately impaired decision-making ability, and documented limited behavioral symptoms such as verbal behaviors toward others and other behaviors toward self on some days. A complaint filed with the State of Michigan alleged the facility refused to readmit the resident after a hospital admission. Review of the electronic medical record showed the resident was transferred to the hospital and that his orders and care plans were discontinued on a later date, and he was no longer a current resident.

Nurse progress notes from the days immediately preceding the transfer documented increased agitation, exit-seeking behaviors, and physical aggression toward staff, with a provider contacted after failed attempts at redirection. However, record review revealed no evidence that a required written Transfer Notice or the facility’s bed-hold policy was provided to the resident or the responsible party following the transfer to the hospital. During interviews, the DON, who had been at the facility for about one month, confirmed the resident had been transferred and had not returned, stated that both a Transfer Notice and bed-hold information should have been provided and documented in the medical record, and reported being unable to locate any evidence that the responsible party was notified in writing of the transfer or bed-hold policy.