Failure to Provide Bed Hold Policy Notice at Hospital Transfer
Penalty
Summary
The facility failed to provide a bed hold policy notice to a resident at the time of discharge to the hospital, as required by its own policy. The facility’s Bed Hold Policy, dated 01/23/08, stated that when a resident is temporarily absent for hospitalization or other leave, the resident may request a bed hold and must be given notice of this option at the time of hospitalization or other leave. Resident #29 was admitted with osteomyelitis and a methicillin susceptible staphylococcus infection, and an admission assessment dated 12/02/25 documented that the resident’s cognition was fully intact with a BIMS score of 14. A discharge assessment dated 12/15/25 showed the resident was discharged to a hospital for a short-term stay. During interview on 01/28/26, Resident #29 stated they were not made aware of the bed hold policy and did not receive a bed hold policy at the time of discharge. On 02/02/26, LPN #1 stated that when a resident was sent to the hospital, it was the case manager’s responsibility to ensure the resident received the bed hold policy, while LPN #2 stated that bed holds were handled by the nurses who sent the resident to the hospital. The ADON stated that when a bed hold policy was provided, it should be documented in the nurse’s notes and confirmed that Resident #29 went to the hospital on 12/15/25, with no documentation in the nurse’s notes showing a bed hold policy was given on that date. These findings demonstrated that the facility did not follow its policy to provide and document bed hold notice at the time of hospitalization for this resident.
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