F0628

B

Failure to Provide Required Bed-Hold Notices at Time of Hospital Transfers

Canonsburg, Pennsylvania Survey Completed on 01-23-2026

Penalty

No penalty information released

Summary

The facility failed to provide residents and/or their representatives with written notice of the facility’s bed-hold policy at the time of transfer to the hospital, as required by 42 CFR §483.15(d) and the facility’s own bed-hold policy. Federal regulation requires two written notices: one at or before admission and another at the time of transfer (or within 24 hours for emergency transfers), explaining the duration of any bed-hold, reserve bed payment policy, and return-to-bed provisions. The facility’s policy dated 8/27/25 stated that residents or their representatives would be informed of the bed-hold and return policy prior to transfers and therapeutic leaves. Surveyors determined, through policy review, clinical record review, and staff interviews, that this requirement was not met for five of six residents reviewed for hospitalization.

For one resident with coronary artery disease, diabetes, and hemiplegia, a progress note documented that the resident was sent to the hospital per MD order and that the spouse was made aware, but the clinical record contained no notation that written bed-hold information was provided at the time of transfer. The electronic medical record’s Forms section also lacked a completed Transfer/Discharge/Bed Hold Form for this hospital discharge. Another resident with CAD, diabetes, and a seizure disorder had multiple documented hospital transfers for pneumonia, transfer from dialysis to the hospital, lethargy and change in mental status, and worsening condition requiring ER evaluation. In each of these instances, progress notes showed that family or POA were notified of the transfers, but there was no documentation that written bed-hold notices were provided, and no corresponding Transfer/Discharge/Bed Hold Forms were found in the Forms section.

A resident with COPD, CKD, hypertension, and a history of stroke was transferred to the ED for a possible neurologic event after slurred speech and tremors were observed during a video assessment; the record lacked any notation of written bed-hold notification and no Transfer/Discharge/Bed Hold Form was present. Another resident with COPD, heart failure, and arthritis requested hospital transfer due to increased lower leg swelling related to cellulitis; the MD ordered the transfer and EMS transported the resident, but again there was no documentation of written bed-hold notice or a completed Transfer/Discharge/Bed Hold Form. A further resident with ALS, hypertension, and a seizure disorder was sent to the hospital after a hospice RN noted significantly decreased respirations and apnea and contacted the resident’s husband, who requested hospital evaluation. For this transfer, a Transfer/Discharge/Bed Hold Form existed but was incomplete, with the section documenting the method of resident or representative notification left blank. In an interview, the Nursing Home Administrator and DON confirmed that the facility did not ensure written bed-hold notice at the time of transfer for five of six residents reviewed for hospitalization.