Failure to Provide Bed-Hold Information and Written Transfer Reasons for Hospital Transfers
Penalty
Summary
The facility failed to provide required bed-hold information and written reasons for transfer for a resident on multiple occasions. The facility’s “Bed Hold and Return to Facility Policy and Procedure,” created in May 2017 and revised in January 2024, states that residents who are transferred to the hospital or go on therapeutic leave are to be provided written information about the State’s bed-hold duration and payment amount before the transfer. The policy also states that residents and their representatives will be provided with bed-hold and return information at admission and before a hospital transfer or therapeutic leave, and that nursing and social work staff are educated on these requirements. Record review showed that one resident, admitted on an unspecified date, was listed on hospital leave on five separate occasions: 11/30/25, 12/01/25, 12/09/25, 12/18/25, and 01/02/26. Progress notes from 11/30/25 at 2:12 AM documented that the doctor’s office was notified and the resident was sent to the emergency room. However, review of the resident’s medical record, including progress notes and miscellaneous documents, revealed no bed-hold information or written reason for transfer for any of the five hospital transfers. In an interview on 1/20/26 at 9:50 AM, the Social Service Director confirmed that the facility had no completed bed-hold forms or reason-for-transfer forms for this resident and acknowledged that one should have been completed with each transfer to the hospital.
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