Failure to Provide Written Bed-Hold Policy and Documentation for Hospitalized Resident
Penalty
Summary
The facility failed to provide a written bed-hold policy, including duration, to a resident who was hospitalized. The resident had diagnoses of diabetes mellitus, major depressive disorder, and a developmental disorder of scholastic skills, and had an MDS BIMS score indicating intact cognition. The resident’s EMR documented admission to the hospital, and a progress note showed that verbal consent for a bed hold was obtained from the resident’s durable power of attorney the following day. However, there was no documentation that a written bed-hold notice, including the policy and duration, was provided to the resident or the DPOA. Staff interviews revealed that nurses obtained verbal bed-hold consents but did not send a bed-hold form with residents when they went to the hospital. Administrative staff reported completing the bed hold verbally with the family member and stated that the form would be sent to the family, but there was no documentation or record that it was actually sent. The social services designee documented only that verbal consent was received and was not aware that a paper copy of the bed-hold notice should be given to the resident or family. Another administrative staff member confirmed the facility had no way to show that a resident or DPOA received a written bed-hold form when the consent was obtained verbally, despite facility instructions stating that the resident or responsible party should be asked whether they wanted to come in to sign or have the bed hold mailed, with the response documented on the form and in the census comments.
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