F0628

D

Failure to Provide Written Transfer Notices and Complete Bed-Hold Documentation for Hospitalized Residents

West Allis, Wisconsin Survey Completed on 01-14-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide required written transfer/discharge notices and complete bed-hold documentation, including the per diem rate, for three residents during hospitalizations. Facility policy titled “Bed Hold Notice” (revised 8/2025) requires that residents and/or their representatives receive written information about bed-hold practices both at admission and at the time of transfer for hospitalization or therapeutic leave, including the duration of any state bed-hold policy, reserve bed payment policy, facility bed-hold policies, and conditions for return. The policy also requires written notice of bed-hold policies within 24 hours of an emergency transfer, documentation of attempts to reach representatives, and retention of a signed and dated copy of the bed-hold notice in the resident’s record. Interviews with the Nursing Home Administrator (NHA) confirmed that the facility only obtains verbal acknowledgement for transfer/discharge and bed-hold notices and does not provide written copies to representatives, and that the per diem rate varies by level of care.

For one resident with quadriplegia, epilepsy, dysphagia, insomnia, anxiety disorder, and major depressive disorder, who was cognitively intact per a BIMS score of 15, the facility completed transfer notices for two hospitalizations. The first transfer notice documented the transfer date, a general reason that the transfer was necessary for the resident’s welfare, and specified “Sent out for NP (nasal prongs)” as the reason, and included required agency contact information for appeals. However, the notice was signed only by a facility employee and not acknowledged by the resident or representative, and there was no documentation that the notice was provided in writing in a language understood by the resident or representative. The associated bed-hold notice did not have the reason for the bed hold (hospital admission vs. therapeutic leave) checked and did not include the facility’s basic per diem rate, although it documented that the POA agreed to the bed hold. For the second hospitalization, the transfer notice again was signed only by a facility employee, did not specify the reason for transfer in the “Specify” field, and there was no evidence that the resident or representative received the notice in writing in a language they understood. The corresponding bed-hold notice indicated admission to the hospital and that the representative requested a bed hold and received verbal notice, but again omitted the basic per diem rate.

For a second resident with acute respiratory failure with hypoxia, tracheostomy status, and cognitive communication deficit, whose MDS documented short- and long-term memory problems and that the resident was rarely understood and rarely understood others, and who had a guardian, multiple hospitalizations occurred. For each hospitalization, the facility generated a notice of transfer and a bed-hold notice. On one hospitalization, the transfer notice contained a signature line for the resident or representative, but there was no guardian signature, and the bed-hold notice showed an LPN consenting to hold the bed without evidence of guardian consent and without a documented daily rate. On a subsequent hospitalization, the same pattern occurred: no guardian signature on the transfer notice, an LPN consenting to the bed hold, and no daily rate on the bed-hold form. For two later hospitalizations, the transfer notices documented that verbal consent was obtained from the guardian, but there was no evidence that written notices were provided to the guardian, and the bed-hold forms again lacked the daily rate. The NHA confirmed that nurses complete these forms, that only verbal consent is obtained, that no written copies are sent to representatives, and that consent to hold a bed should come from the resident or representative, not from facility staff.

For a third resident with chronic respiratory failure, ventilator dependence, encephalopathy, dysphagia, tracheostomy status, and traumatic subdural hemorrhage, who had a legal guardian, similar issues were identified. During one hospitalization, the bed-hold notice showed an LPN signing on the resident representative’s signature line to consent to holding the bed, with no evidence of the guardian’s consent and no daily rate documented. During a later hospitalization, the notice of transfer included a signature line for the resident or representative, but there was no guardian signature, and the bed-hold notice again lacked evidence of guardian consent and did not include the daily rate. In interviews, the NHA reiterated that only verbal consent is obtained for transfer and bed-hold notices, that no written copies are sent to representatives, and that the daily bed-hold rate is only listed in admission paperwork, not on the bed-hold notices themselves. Surveyors noted the absence of written notices to representatives, the lack of resident/representative signatures acknowledging receipt, the improper substitution of staff signatures for representative consent on bed holds, and the omission of the per diem rate on all reviewed bed-hold forms for these residents.