Failure to Provide Bed-Hold Notices and Transfer Clinical Information
Penalty
Summary
The deficiency involves the facility’s failure to provide residents and/or their representatives with written notice of the facility’s bed-hold policy at the time of, or within 24 hours of, transfer to the hospital, as required by facility policy. The Bed-Hold Notice policy dated 1/7/26 states that written information regarding bed-hold practices, including how long a bed can be held during a leave of absence and the cost per day, must be provided well in advance and at the time of transfer, or within 24 hours in the case of an emergency transfer. The policy also requires documentation of multiple attempts to reach the resident representative if notification cannot be completed, and that a signed and dated copy of the bed-hold notice be kept in the resident’s record for all residents regardless of payment source. For four residents reviewed for hospitalization, the clinical records lacked evidence that this written bed-hold information was provided upon transfer or within the required timeframe. The facility also failed to ensure that necessary clinical information was communicated to the receiving health care provider when residents were transferred to the hospital, contrary to its Transfer and Discharge policy dated 1/7/26. That policy requires that, for any transfer to another provider, the receiving provider must be given contact information for the practitioner responsible for the resident’s care, resident representative information, advance directives, information necessary to meet the resident’s needs, special instructions or precautions for ongoing care, and care plan goals. For each of the four residents reviewed, the clinical records did not contain evidence that this required information was communicated to the hospital at the time of transfer. Resident R2, admitted with COPD, epilepsy, and a history of stroke, was transferred to the hospital on 12/8/25, but the record lacked documentation of necessary clinical information being sent and lacked evidence of bed-hold policy notice. Resident R5, with epilepsy, GERD, and paraplegia, was transferred on 12/26/25 with the same documentation gaps. Resident R6, admitted with encephalopathy, hypertension, and anxiety, was transferred on 11/24/25 without documented communication of necessary clinical information or provision of bed-hold notice. Resident R7, with schizoaffective disorder, epilepsy, and GERD, had transfers documented on 11/5/25, 11/17/25, and 12/29/25, and in each instance the record lacked evidence of required clinical information being communicated to the hospital and lacked evidence of bed-hold policy notice. During a telephone interview, the Nursing Home Administrator and DON confirmed that the records for all four residents did not contain this required documentation.
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