Failure to Notify Resident Representative of Bed-Hold Rights at Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to implement its Bed-Holds and Returns policy for a resident who was transferred to a general acute care hospital. The resident, who had diagnoses including anxiety disorder, hematuria, and psychosis, was initially admitted on an unspecified date and had his daughter listed as his responsible party. On January 4, 2026, nursing notes documented that at approximately 4:45 a.m. a CNA sitter informed an RN and LVN that the resident had removed his catheter. The charge nurse and RN found the resident in bed with profuse bleeding from the penis. The RN documented that the resident stated he had purposely pulled out his catheter because he wanted to be sent out, and the sitter witnessed the resident pull out the catheter. The MD was notified, an ambulance was called around 5:00 a.m., and the resident left the facility at 5:05 a.m. with ambulance personnel. A review of the facility’s Bed Hold Policy and Notification form for this resident indicated that the resident’s daughter was notified by phone on January 4, 2026, of the right to hold the bed for seven days and that she declined, but the form did not document the time of the call or the identity of the facility representative. In a subsequent interview, the RN Supervisor stated she did not call the resident’s daughter about the bed hold. The LVN reported that she called the daughter to inform her of the transfer to the hospital but did not inform her about the bed hold. The resident’s daughter stated she had not received any call or mail from the facility regarding the right to exercise the bed hold provision since the transfer. Review of the facility’s Bed-Holds and Returns policy, dated March 2022, with the DON and ADON showed that the policy required residents/representatives to be provided written information about bed-hold policies in advance of transfer and at the time of transfer (or within 24 hours for emergencies). The DON acknowledged the policy was not followed.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.